Provider Demographics
| NPI: | 1780841361 |
|---|---|
| Name: | OWENSBORO HEALTH MEDICAL GROUP, INC. |
| Entity Type: | Organization |
| Organization Name: | OWENSBORO HEALTH MEDICAL GROUP, INC. |
| Other - Org Name: | OWENSBORO HEALTH MEDICAL GROUP - ORTHOPEDICS & SPORTS MEDICINE |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | SECRETARY |
| Authorized Official - Prefix: | |
| 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: | 1201 PLEASANT VALLEY RD |
| Mailing Address - Street 2: | |
| Mailing Address - City: | OWENSBORO |
| Mailing Address - State: | KY |
| Mailing Address - Zip Code: | 42303-9619 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 270-417-4813 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 1301 PLEASANT VALLEY RD STE 202 |
| Practice Address - Street 2: | |
| Practice Address - City: | OWENSBORO |
| Practice Address - State: | KY |
| Practice Address - Zip Code: | 42303 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 270-417-7500 |
| Practice Address - Fax: | 270-417-7509 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | OWENSBORO HEALTH INC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2008-05-21 |
| Last Update Date: | 2022-12-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 174400000X, 207P00000X, 207Q00000X, 207R00000X, 207X00000X, 208000000X, 363LC0200X, 363LF0000X | ||
| KY | 207RH0003X, 207RI0011X, 207V00000X, 363A00000X, 363AM0700X, 363AS0400X, 363L00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 174400000X | Other Service Providers | Specialist | Group - Multi-Specialty | |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
| No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LC0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care 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 | 000000059970 | Other | BCBS - CONVENIENT CARE, TELL CITY & PENNYRILE PULMONARY CRITICAL CARE LOCATIONS |
| KY | 7100197590 | Medicaid | |
| KY | 000000475394 | Other | BCBS-MULTICARE CLINIC |
| KY | 7100118070 | Medicaid | |
| KY | 7100197570 | Medicaid | |
| KY | 7100137590 | Medicaid | |
| KY | 000000519327 | Other | BCBS-WESTERN KENTUCKY RHEUMATOLOGY CENTER |
| IN | 200135730 | Medicaid | |
| KY | 7100135170 | Medicaid | |
| KY | 7100129860 | Medicaid | |
| KY | 7100172490 | Medicaid | |
| KY | 000000475394 | Other | BCBS-MULTICARE CLINIC |
| KY | 7100129860 | Medicaid | |
| KY | CI3440 | Medicare PIN |
