Basic Information
| Provider Information | |||||||||
| NPI: | 1588620868 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. ELIZABETH MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | ST. ELIZABETH CARDIAC SURGEONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1360 DOLWICK DRIVE | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 MEDICAL VILLAGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593019010 | ||||||||
| FaxNumber: | 8593019018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | RITCHEY-BALDWIN | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP OF FINANCE / CFO | ||||||||
| AuthorizedOfficialTelephone: | 8596551642 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 65946097 | 05 | KY | MEDICAID | 200288340 | 05 | IN | MEDICAID |