Provider Demographics
NPI:1548755739
Name:BAPTIST HEALTH MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BAPTIST HEALTH MEDICAL GROUP INC
Other - Org Name:RURAL HEALTH CLINIC WILLIAMSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR REVENUE CYCLE
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:502-253-4911
Mailing Address - Fax:502-489-5752
Practice Address - Street 1:403 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1153
Practice Address - Country:US
Practice Address - Phone:606-549-8244
Practice Address - Fax:606-549-8354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-29
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY900279261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY18-8940OtherMEDICARE
KY7100336420Medicaid