Provider Demographics
NPI:1750954160
Name:ST. ELIZABETH MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:ST. ELIZABETH MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-301-2370
Mailing Address - Street 1:850 THOMAS MORE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017
Mailing Address - Country:US
Mailing Address - Phone:859-301-4525
Mailing Address - Fax:859-301-4935
Practice Address - Street 1:850 THOMAS MORE PARKWAY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-301-4525
Practice Address - Fax:859-301-4935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. ELIZABETH MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100642570Medicaid