Provider Demographics
NPI:1124407069
Name:OWENSBORO HEALTH MEDICAL GROUP INC
Entity Type:Organization
Organization Name:OWENSBORO HEALTH MEDICAL GROUP INC
Other - Org Name:OWENSBORO HEALTH MEDICAL GROUP - FAMILY MEDICINE
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:270-691-8070
Mailing Address - Fax:
Practice Address - Street 1:2816 VEACH RD
Practice Address - Street 2:SUITE 403
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:270-684-1145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OWENSBORO HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-26
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201200950Medicaid
KY7100364320-MDMedicaid
KY7100382410-NPMedicaid
KY7100364320-MDMedicaid