Basic Information
Provider Information | |||||||||
NPI: | 1205214301 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MURRAY-CALLOWAY COUNTY PUBLIC HOSPITAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MURRAY PEDIATICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 S 8TH ST STE 480W | ||||||||
Address2: |   | ||||||||
City: | MURRAY | ||||||||
State: | KY | ||||||||
PostalCode: | 420712403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707530704 | ||||||||
FaxNumber: | 2707522852 | ||||||||
Practice Location | |||||||||
Address1: | 300 S 8TH ST STE 208E | ||||||||
Address2: |   | ||||||||
City: | MURRAY | ||||||||
State: | KY | ||||||||
PostalCode: | 420712472 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707599223 | ||||||||
FaxNumber: | 2707537345 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2015 | ||||||||
LastUpdateDate: | 04/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRADFORD | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 2707621104 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LP0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 208000000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 7100354010 | 05 | KY |   | MEDICAID | 7100353990 | 05 | KY |   | MEDICAID | 7100369640 | 05 | KY |   | MEDICAID |