Basic Information
| Provider Information | |||||||||
| NPI: | 1174697601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAYLOR REGIONAL MEDICAL GROUP,LLC | ||||||||
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| OtherOrganizationName: | TAYLOR REGIONAL PHYSICIANS FOR WOMEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1698 OLD LEBANON RD | ||||||||
| Address2: | SUITE 2B | ||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704653568 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1698 OLD LEBANON RD | ||||||||
| Address2: | SUITE 2B | ||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704653568 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 09/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2704653561 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 367A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207VG0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 7100011140 | 05 | KY | MEDICAID | 7100009880 | 05 | KY | MEDICAID |