Basic Information
| Provider Information | |||||||||
| NPI: | 1649422759 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAYLOR REGIONAL MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | TAYLOR REGIONAL HOSPITALIST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1698 OLD LEBANON RD | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707896082 | ||||||||
| FaxNumber: | 2707896080 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 OLD LEBANON RD | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707896082 | ||||||||
| FaxNumber: | 2707896080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | ANNIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | HOSPITALIST COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2707896082 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363AM0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 208M00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 7100004130 | 05 | KY | MEDICAID | 7100079630 | 01 | MEDICAID NURSE PRACTIONER GROUP | OTHER |