Healthcare Provider Details

I. General information

NPI: 1194161984
Provider Name (Legal Business Name): OWENSBORO HEALTH MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 N MAIN ST
BEAVER DAM KY
42320-8955
US

IV. Provider business mailing address

PO BOX 23229
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-274-4771
  • Fax: 270-274-4884
Mailing address:
  • Phone: 270-688-1330
  • Fax: 270-688-1338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number900257
License Number StateKY

VIII. Authorized Official

Name: RUSSELL S RANALLO
Title or Position: SECRETARY
Credential:
Phone: 270-417-4813