Basic Information
| Provider Information | |||||||||
| NPI: | 1912054388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ERTEL MEDICINE & PEDIATRICS-POWELL, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 296 | ||||||||
| Address2: | |||||||||
| City: | STANTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403800296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066632511 | ||||||||
| FaxNumber: | 6066630711 | ||||||||
| Practice Location | |||||||||
| Address1: | 68 E ELKINS ST | ||||||||
| Address2: | |||||||||
| City: | STANTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403802311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066632511 | ||||||||
| FaxNumber: | 6066630711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 08/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | ERTEL | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6066632511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35650 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 35650 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QR1300X | 35650 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 7100003440 | 05 | KY | MEDICAID |