Basic Information
| Provider Information | |||||||||
| NPI: | 1255805586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST HEALTH MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | BRANNON CROSSING FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910008 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405910008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592605370 | ||||||||
| FaxNumber: | 8592605379 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PROVIDENCE WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403566033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592605370 | ||||||||
| FaxNumber: | 8592605379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2019 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | CLAY | ||||||||
| AuthorizedOfficialFirstName: | DANYEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 5022534911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH MEDICAL GROUP INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 18-4931 | 01 | MEDICARE | OTHER | 7100127930 | 05 | KY | MEDICAID |