Provider Demographics
NPI:1063838456
Name:KENTUCKY ONE HEALTH MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:KENTUCKY ONE HEALTH MEDICAL GROUP, INC.
Other - Org Name:KENTUCKYONE HEALTH PRIMARY CARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPITSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-313-1694
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7840
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:417 RIVER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1272
Practice Address - Country:US
Practice Address - Phone:606-723-0399
Practice Address - Fax:606-723-0379
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENTUCKYONE HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-10
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY183891Medicare Oscar/Certification