Basic Information
| Provider Information | |||||||||
| NPI: | 1356691406 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KNOX HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KNOX COUNTY HOSPITAL SNF | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 80 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | BARBOURVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409067363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065464175 | ||||||||
| FaxNumber: | 6065455511 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | BARBOURVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409067363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065464175 | ||||||||
| FaxNumber: | 6065455511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 09/17/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6065455543 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KNOX HOSPITAL CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100721 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 12504767 | 05 | KY | MEDICAID |