Provider Demographics
NPI:1598056210
Name:COMMONWEALTH OF KENTUCKY
Entity Type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:CENTRAL STATE HOSPITAL PHYSICIANS
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 1:10510 LAGRANGE ROAD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223
Mailing Address - Country:US
Mailing Address - Phone:502-253-7000
Mailing Address - Fax:503-253-7090
Practice Address - Street 1:10510 LAGRANGE ROAD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223
Practice Address - Country:US
Practice Address - Phone:502-253-7000
Practice Address - Fax:503-253-7090
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-28
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2084P0800X
2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65945396Medicaid
KY65945396Medicaid