Basic Information
| Provider Information | |||||||||
| NPI: | 1245370824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSICIAN SERVICES OF MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 MARIE LANGDON DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6065990983 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 MARIE LANGDON DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6065990983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOLEN | ||||||||
| AuthorizedOfficialFirstName: | BENNY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6065985104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 900134 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.