Provider Demographics
NPI:1225238512
Name:WESTLAKE REGIONAL HOSPITAL MEDICAL GROUP
Entity Type:Organization
Organization Name:WESTLAKE REGIONAL HOSPITAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-384-4753
Mailing Address - Street 1:901 WESTLAKE DR
Mailing Address - Street 2:PO BOX 1269
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-1123
Mailing Address - Country:US
Mailing Address - Phone:270-384-4753
Mailing Address - Fax:270-385-9123
Practice Address - Street 1:901 WESTLAKE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-1123
Practice Address - Country:US
Practice Address - Phone:270-384-4753
Practice Address - Fax:270-385-9123
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADAIR CO. HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-24
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100001207P00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65902322Medicaid