Provider Demographics
NPI:1902960487
Name:ST. ELIZABETH MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:ST. ELIZABETH MEDICAL CENTER, INC
Other - Org Name:THE SAINT ELIZABETH MEDICAL VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:RITCHEY-BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-655-1642
Mailing Address - Street 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5401
Mailing Address - Country:US
Mailing Address - Phone:859-301-9025
Mailing Address - Fax:859-301-9028
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5401
Practice Address - Country:US
Practice Address - Phone:859-301-9025
Practice Address - Fax:859-301-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54001912Medicaid