Provider Demographics
NPI:1619156403
Name:CLARK REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:CLARK REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:FRARACCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-745-3500
Mailing Address - Street 1:1107 W LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1169
Mailing Address - Country:US
Mailing Address - Phone:859-745-3500
Mailing Address - Fax:859-745-3450
Practice Address - Street 1:1107 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1169
Practice Address - Country:US
Practice Address - Phone:859-745-3500
Practice Address - Fax:859-745-3450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100073225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45004199Medicaid