Healthcare Provider Details

I. General information

NPI: 1124407069
Provider Name (Legal Business Name): OWENSBORO HEALTH MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2816 VEACH RD SUITE 403
OWENSBORO KY
42303
US

IV. Provider business mailing address

PO BOX 23229
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-684-1145
  • Fax:
Mailing address:
  • Phone: 270-691-8070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN T HACKBARTH JR.
Title or Position: SECRETARY
Credential:
Phone: 270-417-4813