Provider Demographics
NPI:1205101458
Name:KENTUCKYONE HEALTH MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:KENTUCKYONE HEALTH MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CARMEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-313-1713
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:606-330-7835
Practice Address - Fax:606-330-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 207QA0000X, 207QA0505X
KY207R00000X, 207RA0000X, 2081H0002X, 363A00000X, 363L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100200840 (LCSW)Medicaid
IN200434820AMedicaid
KY7100200880 (CRNA)Medicaid
KY000000060604OtherANTHEM GROUP
KY7100161650 (FRAZIER)Medicaid
KY7100200890 (PA)Medicaid
KY7100200870 (MD)Medicaid
KY78904851 (NP)Medicaid
KY7100200870 (MD)Medicaid