Provider Demographics
NPI:1952401218
Name:HENRY COUNTY MEDICAL CENTER PSC
Entity Type:Organization
Organization Name:HENRY COUNTY MEDICAL CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-845-0369
Mailing Address - Street 1:15 SOUTH MAIN STREET BOX 189
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:KY
Mailing Address - Zip Code:40050-0189
Mailing Address - Country:US
Mailing Address - Phone:502-845-7550
Mailing Address - Fax:502-845-5551
Practice Address - Street 1:15 SO MAIN ST.
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:KY
Practice Address - Zip Code:40050
Practice Address - Country:US
Practice Address - Phone:502-845-7550
Practice Address - Fax:502-845-5551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207Q00000X
KY36325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65910200Medicaid
KY000000047168OtherANTHEM
KY1059181OtherPASSPORT ADV. 2434065001
KY000000047168OtherANTHEM