Healthcare Provider Details

I. General information

NPI: 1285909671
Provider Name (Legal Business Name): ELITE EMERGENCY SERVICES OF KENTUCKY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
PRINCETON KY
42445-2430
US

IV. Provider business mailing address

PO BOX 4458 DEPT 176
HOUSTON TX
77210-4458
US

V. Phone/Fax

Practice location:
  • Phone: 270-365-0438
  • Fax:
Mailing address:
  • Phone: 866-434-8164
  • Fax: 615-760-5985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL C. CLEMMONS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 615-928-6275