Basic Information
| Provider Information | |||||||||
| NPI: | 1932383833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CLAIRE MEDICAL CENTER INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DBA ST. CLAIRE REGIONAL ANESTHESIA PROFESSIONALS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 968 | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403510968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067836521 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 MEDICAL CIRCLE | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604078000 | ||||||||
| FaxNumber: | 2604078014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | LLOYD | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6067836500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 6590684400 | 05 | KY | MEDICAID | 7490073900 | 05 | KY | MEDICAID | CD5204 | 01 | KY | MEDICARE RAILROAD | OTHER |