Basic Information
| Provider Information | |||||||||
| NPI: | 1366460818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARK REGIONAL MEDICAL CENTER, INC | ||||||||
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| OtherOrganizationName: | CLARK IMMEDIATE CARE CENTER REHABILITATION | ||||||||
| 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: | 1934 BYPASS RD | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403912389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597450191 | ||||||||
| FaxNumber: | 8597457789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | FRARACCIO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL 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 | 261QP2000X | 100902 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 032043100 | 01 | KY | BLACK LUNG | OTHER | 000000054543 | 01 | KY | BLUE CROSS | OTHER | 01007335 | 05 | KY | MEDICAID |