1306958343 NPI number — MED 1ST OF OWENSBORO

Table of content: (NPI 1306958343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306958343 NPI number — MED 1ST OF OWENSBORO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED 1ST OF OWENSBORO
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:
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:
1306958343
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:
PO BOX 4506
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47724-0506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-471-8630
Provider Business Mailing Address Fax Number:
812-471-8640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 FREDERICA ST
Provider Second Line Business Practice Location Address:
SUITEA
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42301-6981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-926-1774
Provider Business Practice Location Address Fax Number:
270-926-7267
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POELING
Authorized Official First Name:
MARVIN
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
812-471-8630

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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