1538297858 NPI number — G & O OF PADUCAH, INC

Table of content: (NPI 1538297858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538297858 NPI number — G & O OF PADUCAH, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G & O OF PADUCAH, 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:
Provider Other Organization Name Type Code:
6
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:
1538297858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2338 BROADWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42001-7114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-442-3571
Provider Business Mailing Address Fax Number:
270-442-3197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2338 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42001-7114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-442-3571
Provider Business Practice Location Address Fax Number:
270-442-3197
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAGAN
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
270-442-3571

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  P06961 , 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: 54005962 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90000233 . This is a "DURABLE MEDICAL SUPLIES" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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