Healthcare Provider Details

I. General information

NPI: 1073563219
Provider Name (Legal Business Name): ASHLAND MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 KENWOOD DR
RUSSELL KY
41169-1527
US

IV. Provider business mailing address

1061 KENWOOD DR
RUSSELL KY
41169-1527
US

V. Phone/Fax

Practice location:
  • Phone: 606-833-5864
  • Fax: 606-833-9760
Mailing address:
  • Phone: 606-833-5864
  • Fax: 606-833-9760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MOHAMAD RIAD ABUL-KHOUDOUD
Title or Position: PRESIDENT
Credential: MD
Phone: 606-833-5864