Basic Information
| Provider Information | |||||||||
| NPI: | 1952477978 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASHLAND HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KINGS DAUGHTERS CEDAR KNOLL PEDIATRICS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 LEXINGTON AVE | ||||||||
| Address2: | PO BOX 1595 | ||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063275044 | ||||||||
| FaxNumber: | 6063277425 | ||||||||
| Practice Location | |||||||||
| Address1: | 10650 US ROUTE 60 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411029611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063277337 | ||||||||
| FaxNumber: | 6063267798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCDOWELL | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P | ||||||||
| AuthorizedOfficialTelephone: | 6063274404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 65923302 | 05 | KY | MEDICAID | 2701875 | 05 | OH | MEDICAID |