NPIMap

Organization Active NPI

Estill Medical Clinic, PSC

  • Family Medicine Physician
  • Irvine, KY
National Provider Identifier
1154500296
Registry record updated Nov 9, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
ESTILL MEDICAL CLINIC, PSC
Practice address
275 Court St
Irvine, KY 40336-1077
Phone
(606) 723-2167
Fax
(606) 723-2112
NPI assigned
Oct 25, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 9, 2011

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

Authorized official

Name
Donna R Isfort, APRNNPI 1972684215
Title
Owner
Phone
(606) 723-2167

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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

275 Court St
Irvine, KY 40336-1077

Mailing address

275 Court St
Irvine, KY 40336-1077
Phone (606) 723-2167

Other identifiers 2

IdentifierTypeStateIssuer
000000507512OtherKYANTHEM
64142649MedicaidKY

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20080108000027 KY Part B Supplier - Clinic/Group Practice 5597845255 Receives reassigned benefits from 6 practitioners
Practice locations: Irvine, KY
O20090708000679 KY Part A Provider - Rural Health Clinic 5597845255 Practice locations: Irvine, KY

Rural health clinic certification: CCN 188903

Legal name
ESTILL MEDICAL CLINIC, PSC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 23, 2010
Last certification
Aug 22, 2024
Ownership / control type
2B
Organization structure
CorporationProprietary
Incorporated
Jul 1, 2006 in KY
Enrollment address
275 Court St
Irvine, KY 40336-1077

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 1

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

NameRoleSinceShare
Donna Ruth Isfort Individual 5% Or Greater Direct Ownership Interest Aug 1, 2011 100%
Corporate OfficerOwner/Aprn Aug 1, 2011 100%
Corporate DirectorOwner/Aprn Aug 1, 2011 100%
W-2 Managing EmployeeOwner/Aprn Aug 1, 2011

Owners & managing parties with NPI records 1

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

  • Donna R. Isfort, APRN
    • Family Nurse Practitioner
    • Irvine, KY
    • NPI 1972684215

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

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1193270400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1320796800000",
    "number": "1154500296",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "275 COURT ST",
            "city": "IRVINE",
            "state": "KY",
            "postal_code": "403361077",
            "telephone_number": "606-723-2167",
            "fax_number": "606-723-2112"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "275 COURT ST",
            "city": "IRVINE",
            "state": "KY",
            "postal_code": "403361077",
            "telephone_number": "606-723-2167",
            "fax_number": "606-723-2112"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ESTILL MEDICAL CLINIC, PSC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-25",
        "last_updated": "2011-11-09",
        "status": "A",
        "authorized_official_last_name": "ISFORT",
        "authorized_official_first_name": "DONNA",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "606-723-2167",
        "authorized_official_credential": "APRN"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "000000507512",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "64142649",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Irvine, KY

Sources for this page

Verify at the official NPI Registry.