Healthcare Provider Details

I. General information

NPI: 1407044217
Provider Name (Legal Business Name): BAPTIST PHYSICIANS SOUTHEAST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TRILLIUM WAY
CORBIN KY
40701-8426
US

IV. Provider business mailing address

PO BOX 1325
CORBIN KY
40702-1325
US

V. Phone/Fax

Practice location:
  • Phone: 606-526-8131
  • Fax: 606-528-8661
Mailing address:
  • Phone: 606-526-8131
  • Fax: 606-528-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number700214
License Number StateKY
# 13
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number900027
License Number StateKY
# 14
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY
# 15
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5263P
License Number StateKY

VIII. Authorized Official

Name: LARRY GRAY
Title or Position: PRESIDENT/CEO
Credential:
Phone: 606-526-8131