NPIMap

Organization Active NPI

Eastern Kentucky Tender Care Pediatrics LLC

  • Rural Health Clinic/Center
  • Prestonsburg, KY
National Provider Identifier
1043437254
Registry record updated Feb 24, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
EASTERN KENTUCKY TENDER CARE PEDIATRICS LLC
Practice address
400 University Dr Ste 101
Prestonsburg, KY 41653-1080
Phone
(606) 886-1173
Fax
(606) 886-2193
NPI assigned
Apr 19, 2007
Last updated
Feb 24, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 24, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Antoin Hana, M.D.NPI 1669483830
Title
Owner
Phone
(606) 886-1173

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Pediatrics Physician 208000000X NU

Addresses

Primary practice location

400 University Dr Ste 101
Prestonsburg, KY 41653-1080

Mailing address

PO Box 697
Prestonsburg, KY 41653-0697
Phone (606) 886-1173

Other identifiers 1

IdentifierTypeStateIssuer
7100006320MedicaidKY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070425000058 KY Part A Provider - Rural Health Clinic 9537264262 Practice locations: Prestonsburg, KY
O20110311000572 KY Part B Supplier - Clinic/Group Practice 9537264262 Receives reassigned benefits from 27 practitioners
Practice locations: Prestonsburg, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043437254. Details of each certification follow.

Rural health clinic certification: CCN 183914

Legal name
EASTERN KENTUCKY TENDER CARE PEDIATRICS, LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 4, 2003
Last certification
Jan 3, 2018
Ownership / control type
1B
Most recent change of ownership
Apr 13, 2007 (1 total)
Organization structure
LLCProprietary
Incorporated
Dec 11, 2002 in KY
Enrollment address
400 University Dr
Ste 101
Prestonsburg, KY 41653-1080

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Antoin Hana Individual 5% Or Greater Direct Ownership Interest Apr 14, 2007
Corporate Director Apr 14, 2007
W-2 Managing EmployeeMD / Owner Apr 14, 2007 100%
Dianna Craft Individual W-2 Managing EmployeePractice Administrator Oct 12, 2015

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Antoin Hana, M.D.
    • Pediatrics Physician
    • Prestonsburg, KY
    • NPI 1669483830

    5% Or Greater Direct Ownership Interest, Corporate Director, W-2 Managing Employee

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 27

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 27

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176940800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1614124800000",
    "number": "1043437254",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 697",
            "city": "PRESTONSBURG",
            "state": "KY",
            "postal_code": "416530697",
            "telephone_number": "606-886-1173",
            "fax_number": "606-886-2193"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 UNIVERSITY DR STE 101",
            "city": "PRESTONSBURG",
            "state": "KY",
            "postal_code": "416531080",
            "telephone_number": "606-886-1173",
            "fax_number": "606-886-2193"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTERN KENTUCKY TENDER CARE PEDIATRICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-19",
        "last_updated": "2021-02-24",
        "certification_date": "2021-02-24",
        "status": "A",
        "authorized_official_last_name": "HANA",
        "authorized_official_first_name": "ANTOIN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "606-886-1173",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100006320",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Prestonsburg, KY

Sources for this page

Verify at the official NPI Registry.