1194161984 NPI number — OWENSBORO HEALTH MEDICAL GROUP, INC

Table of content: (NPI 1194161984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194161984 NPI number — OWENSBORO HEALTH MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OWENSBORO HEALTH MEDICAL GROUP, INC
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:
OWENSBORO HEALTH MEDICAL GROUP - FAMILY MEDICINE
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:
1194161984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23229
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWENSBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42304-3229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-688-1330
Provider Business Mailing Address Fax Number:
270-688-1338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER DAM
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42320-8955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-274-4771
Provider Business Practice Location Address Fax Number:
270-274-4884
Provider Enumeration Date:
05/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RANALLO
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
270-417-4813

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  900257 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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