NPIMap

Organization Active NPI

Southfork Medical Clinic PLLC

Doing business as South Fork Clinic PLLC

  • Rural Health Clinic/Center
  • Whitley City, KY
National Provider Identifier
1205616265
Registry record updated Nov 25, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTHFORK MEDICAL CLINIC PLLC
Doing business as
South Fork Clinic PLLC
Practice address
57 Medical Lane
Whitley City, KY 42653
Phone
(606) 376-7211
Fax
(606) 376-9219
NPI assigned
Oct 5, 2023
Last updated
Nov 25, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 25, 2025

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

Authorized official

Name
Virginia Ann Correll
Title
Credentialing
Phone
(606) 376-7212

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

57 Medical Lane
Whitley City, KY 42653

Mailing address

PO Box 490
Whitley City, KY 42653-0490
Phone (606) 376-7211

Other names 1

  • SOUTH FORK CLINIC PLLC Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040602001146 KY Part B Supplier - Clinic/Group Practice 7012815616 Receives reassigned benefits from 7 practitioners
1 other NPI on this enrollment
Practice locations: Whitley City, KY
O20240614001045 KY Part A Provider - Rural Health Clinic 7012815616 Practice locations: Whitley City, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1205616265. Details of each certification follow.

Rural health clinic certification: CCN B03962

Legal name
SOUTHFORK MEDICAL CLINIC PLLC
Doing business as
SOUTH FORK CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 30, 2024
Last certification
Feb 18, 2026
Ownership / control type
1A
Organization structure
CorporationProprietary
Incorporated
Sep 6, 2022 in KY
Enrollment address
57 Medical Lane
Whitley City, KY 42653

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
18D2291792South Fork Clinic, PLLC57 Medical Lane, Whitley City, KY 42653Certificate of waiverOct 15, 2027

National Provider Directory

National Provider Directory

Locations

57 Medical Ln
Whitley City, KY 42653
Phone (606) 376-7211

69 S Main St
#3
Whitley City, KY 42653
Phone (606) 376-7212

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
Monica Lawson Individual 5% Or Greater Direct Ownership InterestManaging Member Sep 6, 2002 100%
W-2 Managing EmployeeManaging Member Sep 6, 2002

Practitioners & affiliated clinicians

Practitioners 15

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 15

NPI Registry JSON

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

{
    "created_epoch": "1696464000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1764028800000",
    "number": "1205616265",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 490",
            "city": "WHITLEY CITY",
            "state": "KY",
            "postal_code": "426530490",
            "telephone_number": "606-376-7211"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "57 MEDICAL LANE",
            "city": "WHITLEY CITY",
            "state": "KY",
            "postal_code": "42653",
            "telephone_number": "606-376-7211",
            "fax_number": "606-376-9219"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHFORK MEDICAL CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-10-05",
        "last_updated": "2025-11-25",
        "certification_date": "2025-11-25",
        "status": "A",
        "authorized_official_last_name": "CORRELL",
        "authorized_official_first_name": "VIRGINIA",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "606-376-7212"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SOUTH FORK CLINIC PLLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Whitley City, KY

Sources for this page

Verify at the official NPI Registry.