Basic Information
| Provider Information | |||||||||
| NPI: | 1205883824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASHLAND HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KING'S DAUGHTERS FLATWOODS FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1595 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411051595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064084000 | ||||||||
| FaxNumber: | 6064083719 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 BELLEFONTE RD | ||||||||
| Address2: | |||||||||
| City: | FLATWOODS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411392503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068340125 | ||||||||
| FaxNumber: | 6068340128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | MCDOWELL | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 6064084404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2255376 | 05 | OH | MEDICAID | 65923302 | 05 | KY | MEDICAID |