NPIMap

Organization Active NPI

Leitchfield Pediatric Clinic P.S.C.

  • Rural Health Clinic/Center
  • Leitchfield, KY
National Provider Identifier
1558318543
Registry record updated Oct 20, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
LEITCHFIELD PEDIATRIC CLINIC P.S.C.
Practice address
901 Wallace Ave
Leitchfield, KY 42754-1417
Phone
(270) 259-5641
Fax
(270) 259-5309
NPI assigned
May 27, 2006
Last updated
Oct 20, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 20, 2020

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

Authorized official

Name
Lynn Robinson
Title
Creditialing
Phone
(270) 259-5641

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Pediatric Nurse Practitioner 363LP0200X
Pediatrics Physician 208000000X

Addresses

Primary practice location

901 Wallace Ave
Leitchfield, KY 42754-1417

Mailing address

901 Wallace Ave
Leitchfield, KY 42754-1417
Phone (270) 259-5641

Other identifiers 1

IdentifierTypeStateIssuer
65926883MedicaidKY

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20091117000437 KY Part B Supplier - Clinic/Group Practice 9234187808 Receives reassigned benefits from 10 practitioners
Practice locations: Leitchfield, KY
O20200303001501 KY Part A Provider - Rural Health Clinic 9234187808 Practice locations: Leitchfield, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1558318543. Details of each certification follow.

Rural health clinic certification: CCN B03823

Legal name
LEITCHFIELD PEDIATRIC CLINIC P.S.C.
Doing business as
LEITCHFIELD PEDIATRICS
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 11, 2020
Last certification
Aug 7, 2023
Ownership / control type
1C
Organization structure
CorporationProprietary
Incorporated
Jul 31, 1996 in KY
Enrollment address
901 Wallace Ave
Leitchfield, KY 42754-1417

National Provider Directory

National Provider Directory

Locations

901 Wallace Ave
Leitchfield, KY 42754
Phone (270) 259-5641

908 Wallace Ave
Ste 108
Leitchfield, KY 42754
Phone (270) 259-5641

Interoperability endpoints

  • FHIR API: https://fhir-api.fhirprod.aws.greenwayhealth.com/fhir/R4/2.16.840.1.113883.3.140.61385

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Elizabeth Stivers Individual 5% Or Greater Direct Ownership InterestSecretary Oct 29, 2024 33.3%
Anthony K Smith Individual 5% Or Greater Direct Ownership Interest Oct 1, 2020 33.4%
Corporate DirectorManaging Partner Jul 1, 2016
Stephanie Priddy Individual W-2 Managing Employee Oct 1, 2008
John E Evans Individual 5% Or Greater Direct Ownership Interest Oct 1, 2020 33.3%
Corporate OfficerVice President Jul 1, 2013
Corporate Director Jul 1, 2013

Owners & managing parties with NPI records 3

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

Practitioners & affiliated clinicians

Practitioners 17

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 17

NPI Registry JSON

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

{
    "created_epoch": "1148688000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1603152000000",
    "number": "1558318543",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "901 WALLACE AVE",
            "city": "LEITCHFIELD",
            "state": "KY",
            "postal_code": "427541417",
            "telephone_number": "270-259-5641",
            "fax_number": "270-259-5309"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "901 WALLACE AVE",
            "city": "LEITCHFIELD",
            "state": "KY",
            "postal_code": "427541417",
            "telephone_number": "270-259-5641",
            "fax_number": "270-259-5309"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LEITCHFIELD PEDIATRIC CLINIC P.S.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-27",
        "last_updated": "2020-10-20",
        "certification_date": "2020-10-20",
        "status": "A",
        "authorized_official_last_name": "ROBINSON",
        "authorized_official_first_name": "LYNN",
        "authorized_official_title_or_position": "CREDITIALING",
        "authorized_official_telephone_number": "270-259-5641"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "65926883",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Leitchfield, KY

Sources for this page

Verify at the official NPI Registry.