Provider Demographics
NPI:1326052002
Name:TAYLOR REGIONAL MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:TAYLOR REGIONAL MEDICAL GROUP, LLC
Other - Org Name:TAYLOR REGIONAL SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
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:270-465-3561
Mailing Address - Fax:270-789-6119
Practice Address - Street 1:1698 OLD LEBANON RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9662
Practice Address - Country:US
Practice Address - Phone:270-465-3561
Practice Address - Fax:270-789-6119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X, 363AM0700X
KY363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100428810Medicaid
KY65944449Medicaid
KY7100477070Medicaid