Provider Demographics
NPI:1194262394
Name:KENTUCKYONE HEALTH MEDICAL GROUP INC
Entity type:Organization
Organization Name:KENTUCKYONE HEALTH MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-569-7974
Mailing Address - Street 1:250 E LIBERTY ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1530
Mailing Address - Country:US
Mailing Address - Phone:502-569-7940
Mailing Address - Fax:
Practice Address - Street 1:4620 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:KY
Practice Address - Zip Code:40312-8801
Practice Address - Country:US
Practice Address - Phone:606-663-4243
Practice Address - Fax:606-663-3665
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC HEALTH INITIATIVES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1097815261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDINGMedicare Oscar/Certification