Healthcare Provider Details

I. General information

NPI: 1861248502
Provider Name (Legal Business Name): OWENSBORO HEALTH MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 E PARRISH AVE STE 102-B
OWENSBORO KY
42303-3258
US

IV. Provider business mailing address

PO BOX 23229
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-688-1009
  • Fax: 270-688-1010
Mailing address:
  • Phone: 270-688-1330
  • Fax: 270-688-1338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL S. RANALLO
Title or Position: SECRETARY-CFO
Credential:
Phone: 270-685-7180