Provider Demographics
NPI:1164589842
Name:JENNIE STUART MEDICAL CENTER
Entity Type:Organization
Organization Name:JENNIE STUART MEDICAL CENTER
Other - Org Name:CONVENIENT CARE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PATIENT FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-887-0100
Mailing Address - Street 1:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-2400
Mailing Address - Country:US
Mailing Address - Phone:270-887-0100
Mailing Address - Fax:270-887-0425
Practice Address - Street 1:320 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1965
Practice Address - Country:US
Practice Address - Phone:270-887-0100
Practice Address - Fax:270-887-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6593432500Medicaid
KY000000212362OtherBLUE CROSS PROFESSIONAL
KY0159Medicare ID - Type Unspecified