Provider Demographics
NPI:1053782193
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:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:RANALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-685-7180
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 1:44 MCCOY AVE STE 133
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-2867
Practice Address - Country:US
Practice Address - Phone:270-326-5422
Practice Address - Fax:270-326-5431
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OWENSBORO HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-15
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207RC0000X
208VP0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100378500 - MDMedicaid
KY7100378500 - MDMedicaid