1205101458 NPI number — KENTUCKYONE HEALTH MEDICAL GROUP, INC.

Table of content: (NPI 1205101458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205101458 NPI number — KENTUCKYONE HEALTH MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENTUCKYONE 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:
CHI SAINT JOSEPH MEDICAL GROUP
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:
1205101458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-330-7835
Provider Business Mailing Address Fax Number:
606-330-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 HARRODSBURG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40504-3751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-330-7835
Provider Business Practice Location Address Fax Number:
606-330-7825
Provider Enumeration Date:
03/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
CARMEL
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
859-313-1713

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QA0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0505X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081H0002X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , 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: 7100200840 (LCSW) , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200434820A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100200880 (CRNA) , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000060604 . This is a "ANTHEM GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100161650 (FRAZIER) , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100200890 (PA) , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100200870 (MD) , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 78904851 (NP) , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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