Baptist Health Medical Group Inc
Organization Active NPI Rural Health Clinic/Center · Eddyville, KY
NPI 1689229189 · NPPES record last updated Jul 22, 2024
Key facts
- NPI
- 1689229189
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- BAPTIST HEALTH MEDICAL GROUP INC
- Practice address
- 627 W Fairview Ave
Eddyville, KY 42038-7386 - Phone
- (270) 388-5454
- Fax
- (270) 388-5452
- NPI assigned
- Aug 2, 2019
- Organization subpart
- Yes
- Parent organization (as reported)
- BAPTIST HEALTH MEDICAL GROUP INC
Authorized official
- Name
- Danyel D Clay
- Title
- Vice President Revenue Cycle
- Phone
- (502) 253-4911
Owners & managing parties with NPI records 1
-
Staci Dawn Rogers, M.D.
Other NPIs on the same Medicare enrollment 40
Corporate family (same tax ID) 24
Member of 1
Facilities with the same owner 29
Practitioners 6
-
Diana Blevins, APRN
-
Winston Chua, MD
-
Alexandria Coutts, D.O
-
Amanda Kathleen Curry, APRN
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D0880486 | Baptist Health Medical Group Family Medicine | Certificate of waiver | Jul 31, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in KY
Rural health clinic certification: CCN B03809
- Legal name
- BAPTIST HEALTH MEDICAL GROUP INC
- Doing business as
- EDDYVILLE FAMILY MEDICINE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Nov 26, 2019
- Last certification
- Nov 26, 2019
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jul 21, 2006 in KY
- Enrollment address
- 627 W Fairview Ave
Eddyville, KY 42038-7386
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Staci Dawn Farner Rogers |
Corporate Director |
Jan 1, 2022 | |
| Richard Carrico |
Corporate Officer |
Apr 12, 2023 | |
| Christion Hutson |
Corporate Director |
Jan 1, 2026 | |
| Janet Norton |
Corporate Officer |
Jan 1, 2013 | |
| Frank Purdy |
Corporate Director |
Jan 1, 2022 | |
| Victoria Buster |
Corporate Director |
Jan 1, 2023 | |
| Danyel D Clay |
Corporate Officer |
Jan 1, 2023 | |
| W-2 Managing Employee |
Jan 1, 2023 | ||
| Isaac J Myers |
Corporate Officer |
Jan 10, 2018 | |
| Susan S Tamme |
Corporate Director |
Jan 1, 2026 | |
| Joanne M Berryman |
Corporate Director |
Jan 1, 2024 | |
| Baptist Healthcare System Inc |
5% Or Greater Direct Ownership Interest | Jan 1, 2015 | 100% |
| Ronald Douglas Reed |
Corporate Officer |
Jan 17, 2024 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070228000503 | KY | Part B Supplier - Clinic/Group Practice | 5597867184 |
Receives reassigned benefits from 1,548 practitioners 40 other NPIs on this enrollment This NPI is an additional NPI on the enrollment |
| O20191024001656 | KY | Part a Provider - Rural Health Clinic | 5597867184 | Practice locations: Eddyville, KY |
National Provider Directory
- Tax ID family
- Baptist Health Inc
- Part of
- Baptist Health Inc
Locations
627 W Fairview Ave
Eddyville, KY 42038
Phone (270) 388-5454
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
627 W Fairview Ave
Eddyville, KY 42038-7386
Mailing address
1901 Campus PL
Louisville, KY 40299-2308
Phone (502) 253-4911
Other names
- Eddyville Family Medicine
Other providers in Eddyville, KY
- Denise Evans Adams
- Olivia Lynne Akridge
- Gregory Joe Aldridge
- Tara Alexander
- Kayla Brasher
- April Ann Brown
- C&O Rehabilitation & Fitness, LLC
- Caldwell County Hospital
- Caldwell County Hospital, Inc
All providers in Eddyville, KY · Rural Health Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 22, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.