Provider Demographics
| NPI: | 1609394840 |
|---|---|
| Name: | OWENSBORO HEALTH MEDICAL GROUP, INC. |
| Entity Type: | Organization |
| Organization Name: | OWENSBORO HEALTH MEDICAL GROUP, INC. |
| Other - Org Name: | OWENSBORO HEALTH HENDERSON HEALTHPLEX |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | SECERTARY |
| 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: | 270-417-4813 |
| 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: | 1200 BARRETT BLVD |
| Practice Address - Street 2: | |
| Practice Address - City: | HENDERSON |
| Practice Address - State: | KY |
| Practice Address - Zip Code: | 42420-4950 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 270-844-8600 |
| Practice Address - Fax: | 270-844-8610 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | OWENSBORO HEALTH, INC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2017-09-08 |
| Last Update Date: | 2023-11-27 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 1041C0700X, 213ES0103X | ||
| KY | 207Q00000X, 207QS0010X, 207R00000X, 207X00000X, 208000000X, 2083X0100X, 2085R0202X, 208600000X, 208VP0000X, 363A00000X, 363L00000X, 363LF0000X, 363LP2300X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2083X0100X | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
| No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| KY | 7100502950-PA | Medicaid | |
| KY | 7100504020-MD | Medicaid | |
| KY | 7100495430-NP | Medicaid |
