Provider Demographics
NPI:1336182898
Name:CAVERNA MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:CAVERNA MEMORIAL HOSPITAL, INC.
Other - Org Name:CAVERNA MEMORIAL HOSPITAL PHYSICIAN OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-786-2191
Mailing Address - Street 1:1495 S DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:HORSE CAVE
Mailing Address - State:KY
Mailing Address - Zip Code:42749-1457
Mailing Address - Country:US
Mailing Address - Phone:270-786-2372
Mailing Address - Fax:270-786-2472
Practice Address - Street 1:1495 S DIXIE ST
Practice Address - Street 2:
Practice Address - City:HORSE CAVE
Practice Address - State:KY
Practice Address - Zip Code:42749-1457
Practice Address - Country:US
Practice Address - Phone:270-786-2372
Practice Address - Fax:270-786-2472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 363LF0000X
KY900232261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65929382Medicaid
KY7100146250Medicaid
KY7976Medicare PIN
KY65929382Medicaid