Basic Information
Provider Information | |||||||||
NPI: | 1003490517 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MURRAY-CALLOWAY COUNTY PUBLIC HOSPITAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 803 POPLAR ST | ||||||||
Address2: |   | ||||||||
City: | MURRAY | ||||||||
State: | KY | ||||||||
PostalCode: | 420712432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707621597 | ||||||||
FaxNumber: | 2707621598 | ||||||||
Practice Location | |||||||||
Address1: | 803 POPLAR ST | ||||||||
Address2: |   | ||||||||
City: | MURRAY | ||||||||
State: | KY | ||||||||
PostalCode: | 420712432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707621597 | ||||||||
FaxNumber: | 2707621598 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2021 | ||||||||
LastUpdateDate: | 04/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRADFORD | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO/AO | ||||||||
AuthorizedOfficialTelephone: | 2707621100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.