Provider Demographics
NPI:1659454924
Name:MORGAN-HAUGH PROFESSIONAL SERVICES CORPORATION
Entity Type:Organization
Organization Name:MORGAN-HAUGH PROFESSIONAL SERVICES CORPORATION
Other - Org Name:MORGAN-HAUGH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRAAKSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-650-7138
Mailing Address - Street 1:1111 MEDICAL CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1194
Mailing Address - Country:US
Mailing Address - Phone:270-247-8100
Mailing Address - Fax:270-247-7780
Practice Address - Street 1:1111 MEDICAL CENTER CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1194
Practice Address - Country:US
Practice Address - Phone:270-247-8100
Practice Address - Fax:270-247-7780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207Y00000X
KY41115208000000X
KY00328213E00000X
KY917231H00000X
KY27345261QM1300X
KY2813P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370270Medicaid
KYCE3275OtherRR GRP NO
KY0421OtherMEDICAID SITE
KY6590034200OtherMEDICAID GRP
KYB08239004OtherMEDICARE DME SUBMITTER ID
KYCE3275OtherRR GRP NO
KY3176Medicare ID - Type UnspecifiedSITE NUMBER
KY6590034200OtherMEDICAID GRP