Basic Information
Provider Information | |||||||||
NPI: | 1134180920 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. CLAIRE MEDICAL CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1120 | ||||||||
Address2: |   | ||||||||
City: | OWINGSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 403601120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066746386 | ||||||||
FaxNumber: | 6066743096 | ||||||||
Practice Location | |||||||||
Address1: | 632 SLATE AVE | ||||||||
Address2: |   | ||||||||
City: | OWINGSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 403602206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066746386 | ||||||||
FaxNumber: | 6066743096 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 04/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LLOYD | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 6067836501 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | II | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 700048 | KY | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | 900056 | KY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 080020949 | 01 | KY | RAILROAD MEDICARE INDIV # | OTHER | CEO156 | 01 |   | MEDICARE RAILROAD | OTHER | 080113231 | 01 | KY | RAILROAD MEDICARE INDIV # | OTHER | 080020948 | 01 | KY | RAILROAD MEDICARE INDIV # | OTHER | 020915100 | 01 | KY | FEDERAL BLACK LUNG | OTHER | 080104514 | 01 | KY | RAILROAD MEDICARE INDIV # | OTHER | 7100335590 | 05 | KY |   | MEDICAID | 31000599 | 05 | KY |   | MEDICAID |