Basic Information
| Provider Information | |||||||||
| NPI: | 1144651431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METHODIST HEALTH, INC. | ||||||||
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| OtherOrganizationName: | DEACONESS HENDERSON NEUROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452638706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708277558 | ||||||||
| FaxNumber: | 2708277530 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 N ELM ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424202783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708277193 | ||||||||
| FaxNumber: | 2708277371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2013 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 2708277118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 7100270950 | 05 | KY | MEDICAID |