Basic Information
Provider Information | |||||||||
NPI: | 1700194388 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OH MUHLENBERG, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OWENSBORO HEALTH MUHLENBERG COMMUNITY HOSPITAL FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23229 | ||||||||
Address2: |   | ||||||||
City: | OWENSBORO | ||||||||
State: | KY | ||||||||
PostalCode: | 423043229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2706881330 | ||||||||
FaxNumber: | 2706881338 | ||||||||
Practice Location | |||||||||
Address1: | 2025 W EVERLY BROTHERS BLVD STE 2A | ||||||||
Address2: |   | ||||||||
City: | POWDERLY | ||||||||
State: | KY | ||||||||
PostalCode: | 423675401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2703772626 | ||||||||
FaxNumber: | 2703772777 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2010 | ||||||||
LastUpdateDate: | 06/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HACKBARTH | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
AuthorizedOfficialTelephone: | 2704174813 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 900258 | KY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 7100240880 | 05 | KY |   | MEDICAID |