Basic Information
| Provider Information | |||||||||
| NPI: | 1710009493 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROCKCASTLE VENTURES D.B.A. ROCKCASTLE FAMILY HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROCKCASTLE FAMILY HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 NEWCOMB AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062564148 | ||||||||
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| Practice Location | |||||||||
| Address1: | 140 NEWCOMB AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062564148 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BULLOCK | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6062567761 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65939472 | 05 | KY | MEDICAID |