Healthcare Provider Details

I. General information

NPI: 1295777084
Provider Name (Legal Business Name): WESTERN KENTUCKY GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

996 WILKINSON TRCE SUITE A-10
BOWLING GREEN KY
42103-3407
US

IV. Provider business mailing address

996 WILKINSON TRCE SUITE A-10
BOWLING GREEN KY
42103-3407
US

V. Phone/Fax

Practice location:
  • Phone: 270-393-9829
  • Fax: 270-393-9830
Mailing address:
  • Phone: 270-393-9829
  • Fax: 270-393-9830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHUCK LOCKE
Title or Position: VP
Credential:
Phone: 615-373-7604