MOREHEAD STATE UNIVERSITY

Provider Demographics

• NPI: 1689954232
• Name: MOREHEAD STATE UNIVERSITY
• Entity Type: Organization
• Organization Name: MOREHEAD STATE UNIVERSITY
• Other - Org Name: MOREHEAD STATE UNIVERSITY COUNSEL & HEALTH SERVICES
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: DIRECTOR
• Authorized Official - Prefix: MRS
• Authorized Official - First Name: SHANNON
• Authorized Official - Last Name: SMITH STEPHENS
• Authorized Official - Credentials: DNP, APRN
• Authorized Official - Phone: 606-783-2123
• Mailing Address - Street 1: 112 ALLIE YOUNG HALL
• Mailing Address - City: MOREHEAD
• Mailing Address - State: KY
• Mailing Address - Zip Code: 40351-1684
• Mailing Address - Country: US
• Mailing Address - Phone: 606-783-2885
• Mailing Address - Fax: 606-783-9106
• Practice Address - Street 1: 112 ALLIE YOUNG HALL
• Practice Address - City: MOREHEAD
• Practice Address - State: KY
• Practice Address - Zip Code: 40351-1684
• Practice Address - Country: US
• Practice Address - Phone: 606-783-2885
• Practice Address - Fax: 606-783-9106
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: MOREHEAD STATE UNIVERSITY
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2011-08-26
• Last Update Date: 2017-03-31

Provider Licenses

State	License ID	Taxonomies
KY		101YP2500X, 1041C0700X
KY	0668	103T00000X
		1223G0001X
KY	03203	207Q00000X
KY	3004857	363L00000X
KY	3796P	363L00000X
KY	3002104	363LF0000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	101YP2500X	Behavioral Health & Social Service Providers	Counselor	Professional	Group - Multi-Specialty
No	103T00000X	Behavioral Health & Social Service Providers	Psychologist		Group - Multi-Specialty
No	1041C0700X	Behavioral Health & Social Service Providers	Social Worker	Clinical	Group - Multi-Specialty
No	1223G0001X	Dental Providers	Dentist	General Practice	Group - Multi-Specialty
No	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
KY	000000609845	Other	ANTHEM BCBS
KY	000000623843	Other	ANTHEM BCBS
KY	P00754288	Other	RR MEDICARE
OH	2973242	Medicaid
KY	30610026	Medicaid
KY	K021100	Other	MEDICARE GROUP
	000000231892	Other	ANTHEM BCBS
OH	2826311	Medicaid
KY	7100092610	Medicaid
KY	000000298213	Other	ANTHEM BCBS
KY	7100034230	Medicaid
KY	78010220	Medicaid
IN	248600K	Medicare PIN
KY	7100034230	Medicaid
KY	00934011	Medicare PIN
KY	000000298213	Other	ANTHEM BCBS
KY	K021100	Other	MEDICARE GROUP
KY	P00754288	Other	RR MEDICARE
KY	K028820	Medicare PIN