1093251548 NPI number — OWENSBORO HEALTH MEDICAL GROUP, INC.

Table of content: (NPI 1093251548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093251548 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 - URGENT CARE
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:
1093251548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2018
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:
811 E PARRISH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42303-3258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-691-8040
Provider Business Practice Location Address Fax Number:
270-691-8049
Provider Enumeration Date:
01/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HACKBARTH
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
270-417-4813

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP2300X , 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: 7100444170 - NP , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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