Provider Demographics
NPI:1093251548
Name:OWENSBORO HEALTH MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:OWENSBORO HEALTH MEDICAL GROUP, INC.
Other - Org Name:OWENSBORO HEALTH MEDICAL GROUP - URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:HACKBARTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:270-417-4813
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:811 E PARRISH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3258
Practice Address - Country:US
Practice Address - Phone:270-691-8040
Practice Address - Fax:270-691-8049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OWENSBORO HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-09
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYMD207Q00000X
KYPA363A00000X
363LF0000X
KY363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100444170 - NPMedicaid
KY7100444170 - NPMedicaid