Basic Information
| Provider Information | |||||||||
| NPI: | 1679720114 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CASEY COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CASEY COUNTY FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 112 LIBERTY SQ | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425393392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067875044 | ||||||||
| FaxNumber: | 6067870251 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 LIBERTY SQ | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425393392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067875044 | ||||||||
| FaxNumber: | 6067870251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 02/23/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TUNGATE | ||||||||
| AuthorizedOfficialFirstName: | REX | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6067876275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CASEY COUNTY HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 7100070150 | 05 | KY | MEDICAID |