Provider Demographics
NPI:1831448679
Name:CECIL CLINIC, PLLC
Entity type:Organization
Organization Name:CECIL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:CECIL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:270-575-1010
Mailing Address - Street 1:PO BOX 14252
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4035
Mailing Address - Country:US
Mailing Address - Phone:270-575-1010
Mailing Address - Fax:270-575-1018
Practice Address - Street 1:2670 NEW HOLT RD STE C
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7506
Practice Address - Country:US
Practice Address - Phone:270-575-1010
Practice Address - Fax:270-575-1018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LF0000X, 2080P0006X
KYPA403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100217100Medicaid
KY7100217070Medicaid
KY7100217070Medicaid