Basic Information
| Provider Information | |||||||||
| NPI: | 1649454067 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CASEY COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CASEY COUNTY HOSPITAL MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 187 WOLFORD AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425393278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067876275 | ||||||||
| FaxNumber: | 6067879717 | ||||||||
| Practice Location | |||||||||
| Address1: | 187 WOLFORD AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425393278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067876275 | ||||||||
| FaxNumber: | 6067879717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 11/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | TUNGATE | ||||||||
| AuthorizedOfficialFirstName: | REX | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6067876275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CASEY CO HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2085R0202X | 28235 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207PE0004X | 31531 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 65941304 | 05 | KY | MEDICAID |