Provider Demographics
NPI: | 1770001877 |
---|---|
Name: | OWENSBORO HEALTH MEDICAL GROUP, INC. |
Entity Type: | Organization |
Organization Name: | OWENSBORO HEALTH MEDICAL GROUP, INC. |
Other - Org Name: | OWENSBORO HEALTH MUHLENBERG HEALTHPLEX |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SECRETARY |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | RUSSELL |
Authorized Official - Middle Name: | S |
Authorized Official - Last Name: | RANALLO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 270-417-4813 |
Mailing Address - Street 1: | PO BOX 23229 |
Mailing Address - Street 2: | |
Mailing Address - City: | OWENSBORO |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 42304-3229 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 270-688-1330 |
Mailing Address - Fax: | 270-688-1338 |
Practice Address - Street 1: | 2025 W EVERLY BROTHERS BLVD STE 1A |
Practice Address - Street 2: | |
Practice Address - City: | POWDERLY |
Practice Address - State: | KY |
Practice Address - Zip Code: | 42367-5401 |
Practice Address - Country: | US |
Practice Address - Phone: | 270-377-2600 |
Practice Address - Fax: | 270-377-2610 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | OWENSBORO HEALTH, INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2017-09-08 |
Last Update Date: | 2022-12-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101YP2500X, 1041C0700X | ||
KY | 207Q00000X, 207QS0010X, 207R00000X, 207RC0000X, 207RC0001X, 207RI0011X, 207X00000X, 2085R0202X, 363A00000X, 363AS0400X, 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RC0001X | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | Group - Multi-Specialty |
No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 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 | 7100488520-NP | Medicaid | |
KY | 7100488500-PA | Medicaid | |
KY | 7100489110-MD | Medicaid |