Basic Information
| Provider Information | |||||||||
| NPI: | 1447312129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEWISH HOSPITAL & ST MARY'S HEALTHCARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | KENTUCKYONE PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 534 HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | BRANDENBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401081222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704225000 | ||||||||
| FaxNumber: | 2704225052 | ||||||||
| Practice Location | |||||||||
| Address1: | 534 HILLCREST DRIVE | ||||||||
| Address2: | |||||||||
| City: | BRANDENBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401081222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704225000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 01/13/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCANNELL | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5025874883 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 35000611 | 05 | KY | MEDICAID |