Healthcare Provider Details

I. General information

NPI: 1871952630
Provider Name (Legal Business Name): INTERVENTIONAL PAIN SPECIALISTS OF BOWLING GREEN PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 2ND AVE SUITE C6
BOWLING GREEN KY
42101-1786
US

IV. Provider business mailing address

PO BOX 2675
BOWLING GREEN KY
42102-7675
US

V. Phone/Fax

Practice location:
  • Phone: 270-282-2024
  • Fax: 270-282-2027
Mailing address:
  • Phone: 270-745-7246
  • Fax: 270-282-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT NORMAN
Title or Position: OWNER
Credential: CRNA
Phone: 270-745-7246