Basic Information
Provider Information | |||||||||
NPI: | 1588239669 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAPTIST HEALTH MEDICAL GROUP INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5200 COMMERCE CROSSINGS DR FL 3 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402292182 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022534911 | ||||||||
FaxNumber: | 5022535752 | ||||||||
Practice Location | |||||||||
Address1: | 75 NATURE TRL STE 1 | ||||||||
Address2: |   | ||||||||
City: | RADCLIFF | ||||||||
State: | KY | ||||||||
PostalCode: | 401609111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2703510098 | ||||||||
FaxNumber: | 2703520860 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2021 | ||||||||
LastUpdateDate: | 05/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLAY | ||||||||
AuthorizedOfficialFirstName: | DANYEL | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 5022534911 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 335E00000X |   |   | Y |   | Suppliers | Prosthetic/Orthotic Supplier |   |
No ID Information.