Basic Information
| Provider Information | |||||||||
| NPI: | 1891112173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKYONE HEALTH MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | KENTUCKYONE HEALTH MEDICAL GROUP - DME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307844 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 LONDON MOUNTAIN VIEW DR | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407416601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068640770 | ||||||||
| FaxNumber: | 6068641461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2014 | ||||||||
| LastUpdateDate: | 12/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CARMEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8593131713 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | KY | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.