Healthcare Provider Details

I. General information

NPI: 1740310267
Provider Name (Legal Business Name): SOUTHERN KENTUCKY NEPHROLOGY ASSOCIATES PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 2ND AVE SUITE 203
BOWLING GREEN KY
42101-1778
US

IV. Provider business mailing address

720 2ND AVE SUITE 203
BOWLING GREEN KY
42101-1778
US

V. Phone/Fax

Practice location:
  • Phone: 270-745-1230
  • Fax:
Mailing address:
  • Phone: 270-843-5114
  • Fax: 270-745-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MISTY SMITH
Title or Position: PRACTICE MANAGER
Credential:
Phone: 270-843-5114