Basic Information
| Provider Information | |||||||||
| NPI: | 1932360930 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGHLANDS HOSPITAL CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HRMC EMERGENCY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 KY ROUTE 321 | ||||||||
| Address2: | |||||||||
| City: | PRESTONSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416539113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068868511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5000 KY ROUTE 321 | ||||||||
| Address2: | |||||||||
| City: | PRESTONSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416539113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068868511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLACKWELL | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6068868511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 363L00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.