Provider Demographics
NPI:1558318543
Name:LEITCHFIELD PEDIATRIC CLINIC P.S.C.
Entity type:Organization
Organization Name:LEITCHFIELD PEDIATRIC CLINIC P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDITIALING
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-259-5641
Mailing Address - Street 1:901 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1417
Mailing Address - Country:US
Mailing Address - Phone:270-259-5641
Mailing Address - Fax:270-259-5309
Practice Address - Street 1:901 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1417
Practice Address - Country:US
Practice Address - Phone:270-259-5641
Practice Address - Fax:270-259-5309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65926883Medicaid
KYC75099Medicare UPIN
KY65926883Medicaid