Basic Information
| Provider Information | |||||||||
| NPI: | 1619981339 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAYLOR REGIONAL MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | TAYLOR REGIONAL ORTHOPEDIC GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1698 OLD LEBANON RD | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707896087 | ||||||||
| FaxNumber: | 2707896119 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL PARK DR STE B | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704650632 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2707896087 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207X00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 363L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100011310 | 05 | KY | MEDICAID |