Basic Information
| Provider Information | |||||||||
| NPI: | 1487210654 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST HEALTH MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BENTON RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY STE 129 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534911 | ||||||||
| FaxNumber: | 5024895752 | ||||||||
| Practice Location | |||||||||
| Address1: | 543 POWELL LN | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420255366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704157070 | ||||||||
| FaxNumber: | 2704154071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2019 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLAY | ||||||||
| AuthorizedOfficialFirstName: | DANYEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 5022534911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH MEDICAL GROUP INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.