Basic Information
| Provider Information | |||||||||
| NPI: | 1659454924 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MORGAN-HAUGH PROFESSIONAL SERVICES CORPORATION | ||||||||
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| OtherOrganizationName: | MORGAN-HAUGH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 MEDICAL CENTER CIR | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702478100 | ||||||||
| FaxNumber: | 2702477780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 MEDICAL CENTER CIR | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702478100 | ||||||||
| FaxNumber: | 2702477780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 12/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRAAKSMA | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2706507138 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 00328 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363L00000X | 2813P | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 231H00000X | 917 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Y00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | 41115 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QM1300X | 27345 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 3370270 | 05 | TN | MEDICAID | CE3275 | 01 | KY | RR GRP NO | OTHER | 0421 | 01 | KY | MEDICAID SITE | OTHER | 6590034200 | 01 | KY | MEDICAID GRP | OTHER | B08239004 | 01 | KY | MEDICARE DME SUBMITTER ID | OTHER |