MEDICARE: EGAN CLINIC PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	207R00000X	Internal Medicine Physician	39726	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700150109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EGAN CLINIC PSC

Provider Business Mailing Address
First Line	:	12945 W HIGHWAY 42
Second Line	:
City	:	PROSPECT
State	:	KY
Zip	:	40059-9107
Country	:	US
Telephone Number	:	502-228-7530
Fax Number	:	502-228-7533

Provider Business Practice Location Address
First Line	:	12945 W HIGHWAY 42
Second Line	:
City	:	PROSPECT
State	:	KY
Zip	:	40059-9107
Country	:	US
Telephone Number	:	502-228-7530
Fax Number	:	502-228-7533

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LYNN O EGAN
Credential	:	MD
Telephone Number	:	502-228-7530

Provider Enumeration Date	:	03/02/2012
Last Update Date	:	07/24/2013

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