Basic Information
| Provider Information | |||||||||
| NPI: | 1770210387 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OWENSBORO HEALTH MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23229 | ||||||||
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| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423043229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706881330 | ||||||||
| FaxNumber: | 2706881338 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 WALLACE AVE | ||||||||
| Address2: | |||||||||
| City: | LEITCHFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427542414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702599400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2022 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | RANALLO | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2706857180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OWENSBORO HEALTH, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.