Basic Information
| Provider Information | |||||||||
| NPI: | 1245356781 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOURBON COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOURBON COMMUNITY HOSP ER PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 LINVILLE DR | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403612129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599871018 | ||||||||
| FaxNumber: | 8599871144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT REP | ||||||||
| AuthorizedOfficialTelephone: | 2707449600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000063648 | 01 | KY | BCBS GROUP | OTHER | 65939324 | 05 | KY | MEDICAID |