Provider Demographics
NPI:1295197507
Name:OWENSBORO HEALTH MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:OWENSBORO HEALTH MEDICAL GROUP, INC.
Other - Org Name:OWENSBORO HEALTH MEDICAL GROUP - UROLOGY
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:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:440 HOPKINSVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1124
Practice Address - Country:US
Practice Address - Phone:270-377-2401
Practice Address - Fax:270-377-2404
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OWENSBORO HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-25
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100406450 - MDMedicaid
KY7100406450 - MDMedicaid