Provider Demographics
NPI:1053404210
Name:ESTILL COUNTY HEALTH DEPARTMENT
Entity type:Organization
Organization Name:ESTILL COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-723-5181
Mailing Address - Street 1:365 RIVER DRIVE
Mailing Address - Street 2:PO BOX 115
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-0115
Mailing Address - Country:US
Mailing Address - Phone:606-723-5181
Mailing Address - Fax:606-723-5254
Practice Address - Street 1:365 RIVER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1284
Practice Address - Country:US
Practice Address - Phone:606-723-5181
Practice Address - Fax:606-723-5254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2083P0901X
251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20033015Medicaid
KYSHARONTOtherMEDICARE FLU
KY15000250OtherHANDS PROVIDER #
KY9903Medicare PIN
KY15000250OtherHANDS PROVIDER #
KYC76089Medicare UPIN
KY20033015Medicaid