Basic Information
| Provider Information | |||||||||
| NPI: | 1275790230 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENTUCKY HOSPITAL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLARK REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 W LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403911169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597453500 | ||||||||
| FaxNumber: | 8597453450 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 W LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403911169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597453500 | ||||||||
| FaxNumber: | 8597453450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 05/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | FRARACCIO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DONALD | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8597453500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | KY | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 000000061940 | 01 | KY | ANTHEM BLUE CROSS BLUE SHIELD | OTHER | 000000657636 | 01 | KY | ANTHEM BLUE CROSS BLUE SHEILD REFERENCE LAB | OTHER |