Basic Information
| Provider Information | |||||||||
| NPI: | 1215491311 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METHODIST HEALTH, INC. | ||||||||
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| OtherOrganizationName: | METHODIST FAMILY MEDICINE KLUTEY PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452638706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702707558 | ||||||||
| FaxNumber: | 2708277530 | ||||||||
| Practice Location | |||||||||
| Address1: | 471 KLUTEY PARK PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424203347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708306100 | ||||||||
| FaxNumber: | 2708263089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2019 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | NOLEN | ||||||||
| AuthorizedOfficialFirstName: | BENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 2708277400 | ||||||||
| 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 | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.