Clay City Pediatrics, PSC
Organization Active NPI Primary Care Clinic/Center · Clay City, KY
NPI 1396048872 · NPPES record last updated Mar 20, 2025
Key facts
- NPI
- 1396048872
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Primary Care Clinic/Center 261QP2300X
- License
- 700222 (KY)
- Legal business name
- CLAY CITY PEDIATRICS, PSC
- Practice address
- 98 River St
Clay City, KY 40312-1314 - Phone
- (606) 663-7788
- Fax
- (606) 663-7785
- NPI assigned
- Dec 6, 2010
- Organization subpart
- No
Authorized official
- Name
- Stacey Cain
- Title
- Practice Manager
- Phone
- (606) 663-7788
Owners & managing parties with NPI records 1
Practitioners 10
-
Leslie Rae Cordial, APRN
-
Dorrita Mullins, ARNP
-
Antoin Hana, M.D.
-
Tasha M Russell, D.O
-
Sarah Webb, APRN
-
Audreanna Barnett, APRN
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D2016278 | Clay City Pediatrics | Certificate of waiver | Nov 15, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in KY
Rural health clinic certification: CCN 188927
- Legal name
- CLAY CITY PEDIATRICS, PSC
- Doing business as
- CLAY CITY PEDIATRICS AND PRIMARY CARE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Aug 1, 2013
- Last certification
- Feb 12, 2026
- Ownership / control type
- 1A
- Organization structure
- Corporation · Proprietary
- Incorporated
- Oct 26, 2010 in KY
- Enrollment address
- 98 River St
Clay City, KY 40312-1314
All disclosed owners & managing parties 2
| Name | Role | Since | Share |
|---|---|---|---|
| Stacey N Holland |
W-2 Managing Employee |
Jan 24, 2013 | |
| Mouhamed Ayman Albaree |
5% Or Greater Direct Ownership Interest |
Apr 10, 2025 | 100% |
| Corporate Officer |
Oct 26, 2010 | ||
| Corporate Director |
Oct 26, 2010 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20110209000736 | KY | Part B Supplier - Clinic/Group Practice | 3678753530 |
Receives reassigned benefits from 9 practitioners Practice locations: Clay City, KY |
| O20130320000420 | KY | Part a Provider - Rural Health Clinic | 3678753530 | Practice locations: Clay City, KY |
National Provider Directory
Locations
2161 Lexington Rd
Ste 5
Richmond, KY 40475
Phone (859) 626-7794
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Primary Care Clinic/Center | 261QP2300X | 700222 | KY | Yes |
Addresses
Primary practice location
98 River St
Clay City, KY 40312-1314
Mailing address
PO Box 280
Prestonsburg, KY 41653-0280
Phone (606) 349-8100
Other providers in Clay City, KY
- Briana Acosta
- Mouhamed A Albaree
- Audreanna Barnett
- Andrea Beth Brooks
- Christina Busse
- Leslie Rae Cordial
- Stacy Lynette Crase
- Creekside Child Development Services Inc
- Sandra Crum-Stevens
- Lelia Elam
All providers in Clay City, KY · Primary Care Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 20, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.