Healthcare Provider Details

I. General information

NPI: 1114962867
Provider Name (Legal Business Name): SOUTHERN KENTUCKY UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 ANDREA ST SUITE 103
BOWLING GREEN KY
42104-5852
US

IV. Provider business mailing address

1325 ANDREA ST SUITE 103
BOWLING GREEN KY
42104-5852
US

V. Phone/Fax

Practice location:
  • Phone: 270-796-9191
  • Fax:
Mailing address:
  • Phone: 270-796-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01046326A
License Number StateIN

VIII. Authorized Official

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