Provider Demographics
NPI:1457480949
Name:BAPTIST HEALTH DEACONESS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BAPTIST HEALTH DEACONESS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANYEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-253-4911
Mailing Address - Street 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1010 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:POWDERLY
Practice Address - State:KY
Practice Address - Zip Code:42367-5463
Practice Address - Country:US
Practice Address - Phone:270-377-1600
Practice Address - Fax:270-338-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35002054Medicaid
KY35002054Medicaid