Healthcare Provider Details

I. General information

NPI: 1053341339
Provider Name (Legal Business Name): PARK STREET PARTNERS, L.L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 FAIRWAY ST
BOWLING GREEN KY
42103-2477
US

IV. Provider business mailing address

PO BOX 3240
BOWLING GREEN KY
42102-3240
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-3910
  • Fax: 270-842-7177
Mailing address:
  • Phone: 270-745-1100
  • Fax: 270-745-1156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RONALD G. SOWELL
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 270-745-1536