1255335774 NPI number — OWENSBORO INTERNAL MEDICINE ASSOCIATES

Table of content: (NPI 1255335774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255335774 NPI number — OWENSBORO INTERNAL MEDICINE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OWENSBORO INTERNAL MEDICINE ASSOCIATES
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:
1255335774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 E PARRISH AVE
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
OWENSBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42303-3222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-688-2000
Provider Business Mailing Address Fax Number:
270-666-1204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 E PARRISH AVE
Provider Second Line Business Practice Location Address:
STE 230
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42303-3222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-688-2000
Provider Business Practice Location Address Fax Number:
270-666-1204
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
BILL
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
270-688-1225

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  16324 , 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: 0000000215988 . This is a "BCBS ID NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000050188 . This is a "BCBS ID NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000050189 . This is a "BCBS ID NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65922569 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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