Healthcare Provider Details

I. General information

NPI: 1710219019
Provider Name (Legal Business Name): SOUTHERN KENTUCKY MEDICINE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 WILKINSON TRCE SUITE 100
BOWLING GREEN KY
42103-3404
US

IV. Provider business mailing address

990 WILKINSON TRCE SUITE 100
BOWLING GREEN KY
42103-3404
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-4043
  • Fax: 270-781-4196
Mailing address:
  • Phone: 270-781-4043
  • Fax: 270-781-4196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GARY DUNCAN
Title or Position: VP
Credential:
Phone: 615-376-7600