Provider Demographics
NPI:1588717185
Name:OUR LADY OF THE WAY
Entity type:Organization
Organization Name:OUR LADY OF THE WAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR BUSINESS OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-285-6601
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:KY
Mailing Address - Zip Code:41649-0910
Mailing Address - Country:US
Mailing Address - Phone:606-285-6400
Mailing Address - Fax:606-285-6619
Practice Address - Street 1:11203 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:KY
Practice Address - Zip Code:41649-0910
Practice Address - Country:US
Practice Address - Phone:606-285-6400
Practice Address - Fax:606-285-6619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65904112Medicaid
KY8577Medicare PIN
KY8001Medicare PIN
KY5490Medicare PIN
KY181305Medicare PIN
KY65904112Medicaid
KY18Z305Medicare PIN
KY6649Medicare PIN