Basic Information
| Provider Information | |||||||||
| NPI: | 1235130667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AUSTIN | ||||||||
| FirstName: | CLEGG | ||||||||
| MiddleName: | FARMER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S 8TH ST | ||||||||
| Address2: | STE 208E | ||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420712400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707599223 | ||||||||
| FaxNumber: | 2707537345 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 8TH ST | ||||||||
| Address2: | STE 208E | ||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420712400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707599223 | ||||||||
| FaxNumber: | 2707537345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 10/06/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 12568 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64125685 | 05 | KY | MEDICAID | 000000314718 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER |