Provider Demographics
NPI:1811939366
Name:CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
Entity type:Organization
Organization Name:CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRITT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:606-837-2108
Mailing Address - Street 1:101 CHAD ST
Mailing Address - Street 2:PO BOX39
Mailing Address - City:EVARTS
Mailing Address - State:KY
Mailing Address - Zip Code:40828-8200
Mailing Address - Country:US
Mailing Address - Phone:606-837-2108
Mailing Address - Fax:606-837-9389
Practice Address - Street 1:101 CHAD ST
Practice Address - Street 2:CLOVER FORK CLINIC
Practice Address - City:EVARTS
Practice Address - State:KY
Practice Address - Zip Code:40828-8200
Practice Address - Country:US
Practice Address - Phone:606-837-2108
Practice Address - Fax:606-837-9389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700006261QP2300X
261QR1300X
KY261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31000045Medicaid
KY7100323670Medicaid
KY31000045Medicaid
KY183823Medicare Oscar/Certification