1508861683 NPI number — COMMONWEALTH OF KENTUCKY

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 1508861683 NPI number — COMMONWEALTH OF KENTUCKY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH OF KENTUCKY
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:
WESTERN STATE HOSPITAL
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:
1508861683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2440 RUSSELLVILLE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPKINSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-889-6025
Provider Business Mailing Address Fax Number:
270-886-4487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 RUSSELLVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOPKINSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42240-8095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-889-6025
Provider Business Practice Location Address Fax Number:
270-886-4487
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CRAYCRAFT
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
502-782-6243

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X , with the licence number: 100072 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X , 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)

  • Identifier: 02020022 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65944852 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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