1205017464 NPI number — TAYLOR REGIONAL MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205017464 NPI number — TAYLOR REGIONAL MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAYLOR REGIONAL MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TAYLOR REGIONAL MEDICAL ONCOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205017464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1698 OLD LEBANON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMPBELLSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42718-9662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-789-6087
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 GREENBRIAR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMPBELLSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42718-9616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-789-6166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALDRON
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
COORDINATOR
Authorized Official Telephone Number:
270-465-3561

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100013050 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100477040 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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