Healthcare Provider Details

I. General information

NPI: 1699030031
Provider Name (Legal Business Name): TAYLOR REGIONAL MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 KINGSWOOD DR
CAMPBELLSVILLE KY
42718-9647
US

IV. Provider business mailing address

67 KINGSWOOD DR
CAMPBELLSVILLE KY
42718-9647
US

V. Phone/Fax

Practice location:
  • Phone: 270-849-2379
  • Fax:
Mailing address:
  • Phone: 270-849-2379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBRA ANN WALDRON
Title or Position: COORDINATOR
Credential:
Phone: 270-465-3561