Basic Information
| Provider Information | |||||||||
| NPI: | 1255335774 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OWENSBORO INTERNAL MEDICINE ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OWENSBORO INTERNAL MEDICINE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 E PARRISH AVE | ||||||||
| Address2: | STE 230 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423033222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706882000 | ||||||||
| FaxNumber: | 2706661204 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 E PARRISH AVE | ||||||||
| Address2: | STE 230 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423033222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706882000 | ||||||||
| FaxNumber: | 2706661204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2706881225 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 16324 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0000000215988 | 01 | KY | BCBS ID NUMBER | OTHER | 000000050188 | 01 | KY | BCBS ID NUMBER | OTHER | 000000050189 | 01 | KY | BCBS ID NUMBER | OTHER | 65922569 | 05 | KY | MEDICAID |