MEDICARE: GRAYSON COUNTY HOSPITAL FOUNDATION INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251X00000X	Supports Brokerage Agency	150102	KY
2	251E00000X	Home Health Agency	150102	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000054567	OTHER	KY	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	2432817000	OTHER	KY	PASSPORT ADVANTAGE

General Provider Information

NPI Number	:	1114926854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAYSON COUNTY HOSPITAL FOUNDATION INC.

Provider Business Mailing Address
First Line	:	910 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-1418
Country	:	US
Telephone Number	:	270-259-9525
Fax Number	:	270-259-1670

Provider Business Practice Location Address
First Line	:	910 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-1418
Country	:	US
Telephone Number	:	270-259-9525
Fax Number	:	270-259-1670

Authorized Official
Title or Position	:	DIRECTOR OF HOME HEALTH
Name	:	MRS. MONA GAIL FULKERSON
Credential	:	RN
Telephone Number	:	270-259-9525

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	06/25/2008

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Directions to “GRAYSON COUNTY HOSPITAL FOUNDATION INC. ” Practice Location

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