Basic Information
| Provider Information | |||||||||
| NPI: | 1134264799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROCKCASTLE VENTURES INC. DOING BUSINESS AS ROCKCASTLE CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROCKCASTLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 NEWCOMB AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062565176 | ||||||||
| FaxNumber: | 6062564401 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 NEWCOMB AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062565176 | ||||||||
| FaxNumber: | 6062564401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 06/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | BULLOCK | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6062567761 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39587 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 64035884 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | PA861 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | 4217P | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | 25335 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1881760569 | 01 | KAREN SAYLOR NPI | OTHER | 65917437 | 05 | KY | MEDICAID | 1649298779 | 01 | NPI MICHAEL KEVIN ROWE | OTHER | 64035884 | 05 | KY | MEDICAID | 1912058272 | 01 | DAVID BULLOCK NPI | OTHER | 1639220916 | 01 | GINGER MINK CASH NPI | OTHER | 1205988235 | 01 | ANGIE PARSON WOODS NPI | OTHER |