Provider Demographics
NPI:1063542082
Name:BAPTIST HEALTHCARE AFFILIATES
Entity type:Organization
Organization Name:BAPTIST HEALTHCARE AFFILIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-222-3329
Mailing Address - Street 1:1025 NEW MOODY LN
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9154
Mailing Address - Country:US
Mailing Address - Phone:502-222-3362
Mailing Address - Fax:502-222-8684
Practice Address - Street 1:1025 NEW MOODY LN
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9154
Practice Address - Country:US
Practice Address - Phone:502-222-3362
Practice Address - Fax:502-222-8684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP05196333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54029285Medicaid
KY1817660OtherNCPDP