Basic Information
Provider Information | |||||||||
NPI: | 1013353101 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OWENSBORO HEALTH MEDICAL GROUP, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OWENSBORO HEALTH MEDICAL GROUP - BEHAVIORAL HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23229 | ||||||||
Address2: |   | ||||||||
City: | OWENSBORO | ||||||||
State: | KY | ||||||||
PostalCode: | 423043229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2706881330 | ||||||||
FaxNumber: | 2706881338 | ||||||||
Practice Location | |||||||||
Address1: | 2211 MAYFAIR DR | ||||||||
Address2: | SUITE 409 | ||||||||
City: | OWENSBORO | ||||||||
State: | KY | ||||||||
PostalCode: | 42301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704177980 | ||||||||
FaxNumber: | 2704177989 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2013 | ||||||||
LastUpdateDate: | 09/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RANALLO | ||||||||
AuthorizedOfficialFirstName: | RUSSELL | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 2704174813 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OWENSBORO HEALTH, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LP0808X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 2084P0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.