Healthcare Provider Details

I. General information

NPI: 1306958343
Provider Name (Legal Business Name): MED 1ST OF OWENSBORO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 FREDERICA ST SUITEA
OWENSBORO KY
42301-6981
US

IV. Provider business mailing address

PO BOX 4506
EVANSVILLE IN
47724-0506
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-1774
  • Fax: 270-926-7267
Mailing address:
  • Phone: 812-471-8630
  • Fax: 812-471-8640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARVIN E. POELING
Title or Position: PRESIDENT
Credential: DC
Phone: 812-471-8630