Basic Information
Provider Information | |||||||||
NPI: | 1225016801 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | METHODIST HEALTH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DEACONESS HENDERSON ANESTHESIOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 638704 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452638704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2708277468 | ||||||||
FaxNumber: | 2708317804 | ||||||||
Practice Location | |||||||||
Address1: | 1305 NORTH ELM ST | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | KY | ||||||||
PostalCode: | 42420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2708277700 | ||||||||
FaxNumber: | 2708277469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2006 | ||||||||
LastUpdateDate: | 11/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JENKINS | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 2708277118 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   | 367500000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 74900481 | 05 | KY |   | MEDICAID |