Healthcare Provider Details

I. General information

NPI: 1063410884
Provider Name (Legal Business Name): HENDERSON ORTHOPAEDIC MEDICAL GROUP, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

471 KLUTEY PARK PLAZA DR
HENDERSON KY
42420-3347
US

IV. Provider business mailing address

471 KLUTEY PARK PLAZA DR
HENDERSON KY
42420-3347
US

V. Phone/Fax

Practice location:
  • Phone: 270-830-8032
  • Fax: 270-830-8132
Mailing address:
  • Phone: 270-830-8032
  • Fax: 270-830-8132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateKY

VIII. Authorized Official

Name: DR. JACOB M O'NEILL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 270-830-8032