Provider Demographics
NPI:1710567706
Name:TAYLOR REGIONAL MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:TAYLOR REGIONAL MEDICAL GROUP LLC
Other - Org Name:TAYLOR REGIONAL SCHOOL CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-465-3561
Mailing Address - Street 1:67 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9647
Mailing Address - Country:US
Mailing Address - Phone:270-789-6087
Mailing Address - Fax:270-789-6119
Practice Address - Street 1:219 MEADER ST
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2639
Practice Address - Country:US
Practice Address - Phone:270-789-6112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100760910Medicaid
KY7100773060Medicaid