Provider Demographics
NPI:1205017464
Name:TAYLOR REGIONAL MEDICAL GROUP
Entity Type:Organization
Organization Name:TAYLOR REGIONAL MEDICAL GROUP
Other - Org Name:TAYLOR REGIONAL MEDICAL ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-465-3561
Mailing Address - Street 1:1698 OLD LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9662
Mailing Address - Country:US
Mailing Address - Phone:270-789-6087
Mailing Address - Fax:
Practice Address - Street 1:125 GREENBRIAR DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9616
Practice Address - Country:US
Practice Address - Phone:270-789-6166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207RH0003X, 363LF0000X
2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100013050Medicaid
KY7100477040Medicaid