Provider Demographics
NPI:1740432053
Name:TAYLOR REGIONAL MEDICAL GROUP,LLC
Entity Type:Organization
Organization Name:TAYLOR REGIONAL MEDICAL GROUP,LLC
Other - Org Name:TAYLOR REGIONAL UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-465-3561
Mailing Address - Street 1:1698 OLD LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9662
Mailing Address - Country:US
Mailing Address - Phone:270-789-6087
Mailing Address - Fax:270-789-6119
Practice Address - Street 1:1698 OLD LEBANON RD
Practice Address - Street 2:SUITE 3B
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718
Practice Address - Country:US
Practice Address - Phone:270-789-2445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-17
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100598820Medicaid
KY7100079630Medicaid
KY7100071450Medicaid