Provider Demographics
NPI:1285909671
Name:ELITE EMERGENCY SERVICES OF KENTUCKY, PLLC
Entity type:Organization
Organization Name:ELITE EMERGENCY SERVICES OF KENTUCKY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLEMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-928-6275
Mailing Address - Street 1:PO BOX 4458
Mailing Address - Street 2:DEPT 176
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4458
Mailing Address - Country:US
Mailing Address - Phone:866-434-8164
Mailing Address - Fax:615-760-5985
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-2430
Practice Address - Country:US
Practice Address - Phone:270-365-0438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100200270Medicaid
KYK045730Medicare PIN
3729999Medicare PIN