Provider Demographics
| NPI: | 1770001877 |
|---|---|
| Name: | OWENSBORO HEALTH MEDICAL GROUP, INC. |
| Entity type: | Organization |
| Organization Name: | OWENSBORO HEALTH MEDICAL GROUP, INC. |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | SECRETARY |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | RUSSELL |
| Authorized Official - Middle Name: | S |
| Authorized Official - Last Name: | RANALLO |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 270-417-4813 |
| Mailing Address - Street 1: | PO BOX 23229 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | OWENSBORO |
| Mailing Address - State: | KY |
| Mailing Address - Zip Code: | 42304-3229 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 270-688-1330 |
| Mailing Address - Fax: | 270-688-1338 |
| Practice Address - Street 1: | 2025 W EVERLY BROTHERS BLVD STE 1A |
| Practice Address - Street 2: | |
| Practice Address - City: | POWDERLY |
| Practice Address - State: | KY |
| Practice Address - Zip Code: | 42367-5401 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 270-377-2600 |
| Practice Address - Fax: | 270-377-2610 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | OWENSBORO HEALTH, INC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2017-09-08 |
| Last Update Date: | 2024-07-29 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101YP2500X, 1041C0700X, 2081P2900X, 363LP0200X | ||
| KY | 207QS0010X, 207R00000X, 207RC0000X, 207RC0001X, 207RI0011X, 207X00000X, 2085R0202X, 363A00000X, 363AS0400X, 363LF0000X, 207Q00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RC0001X | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | Group - Multi-Specialty |
| No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 2081P2900X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| KY | 7100488520-NP | Medicaid | |
| KY | 7100488500-PA | Medicaid | |
| KY | 7100489110-MD | Medicaid |
