Provider Demographics
NPI:1508861683
Name:COMMONWEALTH OF KENTUCKY
Entity Type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:WESTERN STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAYCRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-782-6243
Mailing Address - Street 1:2440 RUSSELLVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240
Mailing Address - Country:US
Mailing Address - Phone:270-889-6025
Mailing Address - Fax:270-886-4487
Practice Address - Street 1:2400 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-8095
Practice Address - Country:US
Practice Address - Phone:270-889-6025
Practice Address - Fax:270-886-4487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-16
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X
KY100072283Q00000X
KY283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes283Q00000XHospitalsPsychiatric Hospital
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY02020022Medicaid
KY65944852Medicaid
KY02020022Medicaid