Healthcare Provider Details

I. General information

NPI: 1700150109
Provider Name (Legal Business Name): EGAN CLINIC PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12945 W HIGHWAY 42
PROSPECT KY
40059-9107
US

IV. Provider business mailing address

12945 W HIGHWAY 42
PROSPECT KY
40059-9107
US

V. Phone/Fax

Practice location:
  • Phone: 502-228-7530
  • Fax: 502-228-7533
Mailing address:
  • Phone: 502-228-7530
  • Fax: 502-228-7533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39726
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: LYNN O EGAN
Title or Position: PRESIDENT
Credential: MD
Phone: 502-228-7530