Healthcare Provider Details

I. General information

NPI: 1558779009
Provider Name (Legal Business Name): OWENSBORO HEALTH MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BRECKENRIDGE ST STE 303
OWENSBORO KY
42303-0877
US

IV. Provider business mailing address

PO BOX 23229
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-688-2720
  • Fax: 270-688-2729
Mailing address:
  • Phone: 270-688-1330
  • Fax: 270-688-1338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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