Provider Demographics
NPI:1487812384
Name:OWENSBORO MEDICAL PRACTICE LABORATORY
Entity type:Organization
Organization Name:OWENSBORO MEDICAL PRACTICE LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KISHOR
Authorized Official - Middle Name:N
Authorized Official - Last Name:VORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,FACC,FSCAI
Authorized Official - Phone:270-683-8672
Mailing Address - Street 1:1200 BRECKENRIDGE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1089
Mailing Address - Country:US
Mailing Address - Phone:270-683-8672
Mailing Address - Fax:270-685-8233
Practice Address - Street 1:1200 BRECKENRIDGE ST
Practice Address - Street 2:STE 101
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1089
Practice Address - Country:US
Practice Address - Phone:270-683-8672
Practice Address - Fax:270-685-8233
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OWENSBORO MEDICAL PRACTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200274291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1851315105OtherNPI
KY64287535Medicaid
KY64287535Medicaid