NPIMap

Organization Active NPI

Southfork Medical Clinic PLLC

  • Specialist
  • Whitley City, KY
National Provider Identifier
1295718757
Registry record updated Aug 23, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
Legal business name
SOUTHFORK MEDICAL CLINIC PLLC
Practice address
71 Medical LN
Whitley City, KY 42653-4216
Phone
(606) 376-7212
Fax
(606) 376-7216
NPI assigned
Nov 29, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 23, 2011

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

Authorized official

Name
Francis Pimentel, MD
Title
Medical Director
Phone
(606) 376-7212

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X Primary

Addresses

Primary practice location

71 Medical LN
Whitley City, KY 42653-4216

Mailing address

71 Medical LN
Whitley City, KY 42653-4216
Phone (606) 376-7212

Other identifiers 2

IdentifierTypeStateIssuer
07396OtherKYMEDICARE B
35001593MedicaidKY

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031220000018 KY Part A Provider - Rural Health Clinic 7012815616 Practice locations: Whitley City, KY
O20040602001146 KY Part B Supplier - Clinic/Group Practice 7012815616 Receives reassigned benefits from 7 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Whitley City, KY

Rural health clinic certification: CCN 183920

Legal name
SOUTHFORK MEDICAL CLINIC PLLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 11, 2003
Last certification
Sep 29, 2017
Ownership / control type
1A
Organization structure
CorporationProprietary
Enrollment address
71 Medical LN
Whitley City, KY 42653-4216

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.

National Provider Directory

National Provider Directory

Locations

71 Medical Ln
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 Interest Nov 13, 2002
W-2 Managing Employee Nov 13, 2002

Practitioners & affiliated clinicians

Practitioners 9

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": "1133222400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1314057600000",
    "number": "1295718757",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "71 MEDICAL LN",
            "city": "WHITLEY CITY",
            "state": "KY",
            "postal_code": "426534216",
            "telephone_number": "606-376-7212",
            "fax_number": "606-376-7216"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "71 MEDICAL LN",
            "city": "WHITLEY CITY",
            "state": "KY",
            "postal_code": "426534216",
            "telephone_number": "606-376-7212",
            "fax_number": "606-376-7216"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHFORK MEDICAL CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-29",
        "last_updated": "2011-08-23",
        "status": "A",
        "authorized_official_last_name": "PIMENTEL",
        "authorized_official_first_name": "FRANCIS",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "606-376-7212",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE B",
            "identifier": "07396",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "35001593",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Whitley City, KY

Sources for this page

Verify at the official NPI Registry.