MEDICARE: EASTERN KY TENDER CARE PEDIATRICS, LLC

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	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000260816	OTHER	KY	ANTHEM BCBS

General Provider Information

NPI Number	:	1831190115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN KY TENDER CARE PEDIATRICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 697
Second Line	:
City	:	PRESTONSBURG
State	:	KY
Zip	:	41653-0697
Country	:	US
Telephone Number	:	606-886-7517
Fax Number	:	606-886-7524

Provider Business Practice Location Address
First Line	:	5000 KY ROUTE 321
Second Line	:	SUITE 3141
City	:	PRESTONSBURG
State	:	KY
Zip	:	41653-9113
Country	:	US
Telephone Number	:	606-886-7517
Fax Number	:	606-886-7524

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANTOIN HANA
Credential	:	M.D.
Telephone Number	:	606-886-7517

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	08/22/2020

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