Healthcare Provider Details

I. General information

NPI: 1346781499
Provider Name (Legal Business Name): CLARK EMERGENCY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 HOSPITAL DR
WINCHESTER KY
40391-9591
US

IV. Provider business mailing address

25 E HICKMAN ST
WINCHESTER KY
40391-2448
US

V. Phone/Fax

Practice location:
  • Phone: 859-737-6500
  • Fax: 859-737-6601
Mailing address:
  • Phone: 859-901-0012
  • Fax: 859-901-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSE DEAN
Title or Position: MEMBER MANAGER
Credential: DO
Phone: 215-858-2323