Basic Information
| Provider Information | |||||||||
| NPI: | 1447437116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KITECK | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | SHAIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 JAMESTOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427281010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703844764 | ||||||||
| FaxNumber: | 2703846228 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 JAMESTOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427281010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703844764 | ||||||||
| FaxNumber: | 2703846228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 03065 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100058480 | 05 | KY | MEDICAID |