Provider Demographics
NPI:1497193767
Name:OWENSBORO HEALTH MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:OWENSBORO HEALTH MEDICAL GROUP, INC
Other - Org Name:OWENSBORO HEALTH MEDICAL GROUP - NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:RANALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-691-8214
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 1:1301 PLEASANT VALLEY RD STE 300
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-417-7830
Practice Address - Fax:270-417-7839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2084N0400X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201200950Medicaid
KY7100252980Medicaid
KY7100414260Medicaid
KY3977OtherKY MEDICARE