Basic Information
Provider Information | |||||||||
NPI: | 1518051762 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLARK REGIONAL MEDICAL CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 950 | ||||||||
Address2: | 1107 WEST LEXINGTON AVENUE | ||||||||
City: | WINCHESTER | ||||||||
State: | KY | ||||||||
PostalCode: | 403920950 | ||||||||
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: | 10/03/2006 | ||||||||
LastUpdateDate: | 05/20/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FRARACCIO | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | DONALD | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8597453500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 100073 | KY | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
ID Information
ID | Type | State | Issuer | Description | 12700084 | 05 | KY |   | MEDICAID |