Basic Information
| Provider Information | |||||||||
| NPI: | 1255645040 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROCKCASTLE COUNTY HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROCKCASTLE FAMILY WELLNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 NEWCOMB AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062564148 | ||||||||
| FaxNumber: | 6062567410 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 NEWCOMB AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062564148 | ||||||||
| FaxNumber: | 6062567410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2010 | ||||||||
| LastUpdateDate: | 02/28/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BULLOCK | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6062567761 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 261QR1300X | 100374 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 900239 | 01 | KY | STATE LICENSE NUMBER | OTHER | K017200 | 01 | MEDICARE PART B | OTHER |