Basic Information
| Provider Information | |||||||||
| NPI: | 1639334261 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METHODIST HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METHODIST PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452638706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708277558 | ||||||||
| FaxNumber: | 2708277530 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 N ELM ST | ||||||||
| Address2: | SUITE 1B | ||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708448144 | ||||||||
| FaxNumber: | 2708448145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | NOLEN | ||||||||
| AuthorizedOfficialFirstName: | BENNY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2708277500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100244590 | 05 | KY | MEDICAID | 7100057700 | 05 | KY | MEDICAID |