Provider Demographics
NPI:1689778250
Name:MARSHALL COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:MARSHALL COUNTY HOSPITAL DISTRICT
Other - Org Name:MARSHALL CO SURGICAL & MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-527-4852
Mailing Address - Street 1:619 OLD SYMSONIA RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-5094
Mailing Address - Country:US
Mailing Address - Phone:270-527-2411
Mailing Address - Fax:270-527-8734
Practice Address - Street 1:619 OLD SYMSONIA RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5094
Practice Address - Country:US
Practice Address - Phone:270-527-2411
Practice Address - Fax:270-527-8734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP638207Q00000X
KY24262207Q00000X
KY17956207R00000X
KY21862207RE0101X
KY24325207X00000X
KYPA540363AM0700X
KY2422P363LF0000X
KY034466367500000X
KY1026012367500000X
KY1027758367500000X
KY1559A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01015338Medicaid
KY000000054610OtherBLUE CROSS
KY78905304Medicaid
KY000000057043OtherBLUE CROSS AND BLUE SHIEL
110104797OtherRR MEDICARE
KYDF7240OtherRR MEDICARE
KY65912362Medicaid
KY=========OtherCOMMERCIAL
KYDF7240OtherRR MEDICARE