Basic Information
| Provider Information | |||||||||
| NPI: | 1184119398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST HEALTH MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | RURAL HEALTH CLINIC BARBOURVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 COMMERCE CROSSINGS DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402292182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534911 | ||||||||
| FaxNumber: | 5024895752 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 KNOX ST | ||||||||
| Address2: | |||||||||
| City: | BARBOURVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409061304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065466027 | ||||||||
| FaxNumber: | 6065462084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLAY | ||||||||
| AuthorizedOfficialFirstName: | DANYEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 5022534911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 18-8935 | 01 | KY | MEDICARE | OTHER | 7100315380 | 05 | KY | MEDICAID |