Provider Demographics
NPI:1043343536
Name:OWENSBORO HEALTH MEDICAL GROUP, INC
Entity type:Organization
Organization Name:OWENSBORO HEALTH MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:RANALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-417-4813
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:510 RUBY DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-2168
Practice Address - Country:US
Practice Address - Phone:270-399-7900
Practice Address - Fax:270-399-7910
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OWENSBORO HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-13
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200235291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY200235OtherSTATE LICENSURE NUMBER
KY200235OtherSTATE LICENSURE NUMBER
KY000000518828OtherANTHEM LAB GROUP # - CHS