Provider Demographics
NPI:1710001185
Name:ST. ELIZABETH MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:ST. ELIZABETH MEDICAL CENTER, INC.
Other - Org Name:ST. ELIZABETH CENTER FOR FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR FAMILY PRACTICE CENTER ADM
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-301-3800
Mailing Address - Street 1:413 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5446
Mailing Address - Country:US
Mailing Address - Phone:859-301-3800
Mailing Address - Fax:859-301-3987
Practice Address - Street 1:413 S LOOP RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5446
Practice Address - Country:US
Practice Address - Phone:859-301-3800
Practice Address - Fax:859-301-3987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. ELIZABETH MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-19
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65901688Medicaid
KY65901688Medicaid