Basic Information
| Provider Information | |||||||||
| NPI: | 1073817581 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAYLOR REGIONAL MEDICAL GROUP LLC | ||||||||
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| OtherOrganizationName: | TAYLOR REGIONAL ENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1698 OLD LEBANON RD | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704653595 | ||||||||
| FaxNumber: | 2707896119 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 GREENBRIAR DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704653595 | ||||||||
| FaxNumber: | 2707892044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2010 | ||||||||
| LastUpdateDate: | 03/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2707896087 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 237600000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100157910 | 05 | KY | MEDICAID | 7100149690 | 05 | KY | MEDICAID |