Basic Information
| Provider Information | |||||||||
| NPI: | 1740432053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAYLOR REGIONAL MEDICAL GROUP,LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TAYLOR REGIONAL UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1698 OLD LEBANON RD | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707896087 | ||||||||
| FaxNumber: | 2707896119 | ||||||||
| Practice Location | |||||||||
| Address1: | 1698 OLD LEBANON RD | ||||||||
| Address2: | SUITE 3B | ||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707892471 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2008 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2704653561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100071450 | 05 | KY | MEDICAID |