Basic Information
| Provider Information | |||||||||
| NPI: | 1588067268 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST HEALTH MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAPTIST PHYSICIANS SOUTHEAST RADIOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 TRILLIUM WAY | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065238542 | ||||||||
| FaxNumber: | 6065288661 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 TRILLIUM WAY | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065238542 | ||||||||
| FaxNumber: | 6065288661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2014 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLAY | ||||||||
| AuthorizedOfficialFirstName: | DANYEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 5022534911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.