Provider Demographics
NPI:1255335774
Name:OWENSBORO INTERNAL MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:OWENSBORO INTERNAL MEDICINE ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-688-1225
Mailing Address - Street 1:815 E PARRISH AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3222
Mailing Address - Country:US
Mailing Address - Phone:270-688-2000
Mailing Address - Fax:270-666-1204
Practice Address - Street 1:815 E PARRISH AVE
Practice Address - Street 2:STE 230
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3222
Practice Address - Country:US
Practice Address - Phone:270-688-2000
Practice Address - Fax:270-666-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16324174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0000000215988OtherBCBS ID NUMBER
KY000000050188OtherBCBS ID NUMBER
KY000000050189OtherBCBS ID NUMBER
KY65922569Medicaid
KY0000000215988OtherBCBS ID NUMBER
KY65922569Medicaid