Provider Demographics
NPI:1811913668
Name:CLARK REGIONAL MEDICAL CENTER, INC
Entity type:Organization
Organization Name:CLARK REGIONAL MEDICAL CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:FRARACCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-745-3500
Mailing Address - Street 1:1107 W LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-0950
Mailing Address - Country:US
Mailing Address - Phone:606-663-4758
Mailing Address - Fax:606-663-8034
Practice Address - Street 1:68 EAST ELKINS STREET
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380-0190
Practice Address - Country:US
Practice Address - Phone:606-663-4758
Practice Address - Fax:606-663-8034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100874261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY032043100OtherBLACK LUNG
KY000000054543OtherBLUE CROSS
KY01007335Medicaid
KY032043100OtherBLACK LUNG