Basic Information
| Provider Information | |||||||||
| NPI: | 1518914670 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASHLAND HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KING'S DAUGHTERS BURLINGTON FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1595 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411051595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 384 COUNTY ROAD 120 S | ||||||||
| Address2: | |||||||||
| City: | SOUTH POINT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456807807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408942080 | ||||||||
| FaxNumber: | 7408945406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 08/25/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITLATCH | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6064084401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207Q00000X | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100222910 | 05 | KY | MEDICAID | 7100222900 | 05 | KY | MEDICAID | 2255376 | 05 | OH | MEDICAID |