Basic Information
| Provider Information | |||||||||
| NPI: | 1447209119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVINGSTON HOSPITAL AND HEALTHCARE SERVICES, INC., CAH | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARION PHYSICIAN'S CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420788043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709882299 | ||||||||
| FaxNumber: | 2709883900 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420641543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709654377 | ||||||||
| FaxNumber: | 2709659569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 04/07/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUDNICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2709882299 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 600071 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 65944019 | 05 | KY | MEDICAID |