Basic Information
| Provider Information | |||||||||
| NPI: | 1588637425 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROCKCASTLE COUNTY HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROCKCASTLE HOSPITAL HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 LEWIS ST | ||||||||
| Address2: | P O BOX 1186 | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062562195 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 145 LEWIS ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062562195 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 03/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | BLACK | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6062562195 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 251E00000X | 150179 | KY | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 150179 | 01 | KY | STATE ID | OTHER | 34000034 | 05 | KY | MEDICAID | 000000203172 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER | 42000083 | 01 | KY | WAIVER | OTHER | 45002045 | 01 | KY | EPSDT | OTHER | C-76 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER |