Basic Information
| Provider Information | |||||||||
| NPI: | 1992292288 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OWENSBORO HEALTH MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OWENSBORO HEALTH SURGICAL WEIGHT LOSS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23229 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423043229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706881330 | ||||||||
| FaxNumber: | 2706881338 | ||||||||
| Practice Location | |||||||||
| Address1: | 2235 MAYFAIR DR | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706881500 | ||||||||
| FaxNumber: | 2706881501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2018 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RANALLO | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 2706857180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OWENSBORO HEALTH INC | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 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 | 207RB0002X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine |
No ID Information.