Basic Information
| Provider Information | |||||||||
| NPI: | 1043343536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OWENSBORO HEALTH MEDICAL GROUP, INC | ||||||||
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| OtherOrganizationName: | OWENSBORO HEALTH MADISONVILLE HEALTHPLEX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23229 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423043229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706881330 | ||||||||
| FaxNumber: | 2706881338 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 RUBY DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424312168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703997900 | ||||||||
| FaxNumber: | 2703997910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 2704174813 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OWENSBORO HEALTH INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 200235 | KY | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 200235 | 01 | KY | STATE LICENSURE NUMBER | OTHER |