Provider Demographics
NPI:1477914927
Name:OWENSBORO HEALTH MEDICAL GROUP INC
Entity Type:Organization
Organization Name:OWENSBORO HEALTH MEDICAL GROUP INC
Other - Org Name:OWENSBORO HEALTH MEDICAL GROUP - EDUCATION & WELLNESS PROGRAMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECERTARY
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:270-691-8070
Mailing Address - Fax:270-691-8026
Practice Address - Street 1:2401 NEW HARTFORD RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1312
Practice Address - Country:US
Practice Address - Phone:270-688-5147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OWENSBORO HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-11
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1041C0700X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty