Healthcare Provider Details

I. General information

NPI: 1720376411
Provider Name (Legal Business Name): TAYLOR REGIONAL MEDICAL GROUP,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 OLD LEBANON RD SUITE 2A
CAMPBELLSVILLE KY
42718-9662
US

IV. Provider business mailing address

1698 OLD LEBANON RD
CAMPBELLSVILLE KY
42718-9662
US

V. Phone/Fax

Practice location:
  • Phone: 270-789-6116
  • Fax: 270-789-6119
Mailing address:
  • Phone: 270-789-0587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID MASSENGALE
Title or Position: CFO
Credential:
Phone: 270-465-3561