Provider Demographics
NPI:1114346467
Name:COMMONWEALTH OF KENTUCKY
Entity Type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:HAZELWOOD SPECIALTY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ACTING COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAYCRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-782-6243
Mailing Address - Street 1:1800 BLUEGRASS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1130
Mailing Address - Country:US
Mailing Address - Phone:502-361-2301
Mailing Address - Fax:502-366-0367
Practice Address - Street 1:1800 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1130
Practice Address - Country:US
Practice Address - Phone:502-361-2301
Practice Address - Fax:502-366-0367
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-15
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty