Healthcare Provider Details

I. General information

NPI: 1790075273
Provider Name (Legal Business Name): WESTERN KENTUCKY UNIVERSITY SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 AVENUE OF CHAMPIONS RM 128
BOWLING GREEN KY
42101-6412
US

IV. Provider business mailing address

PO BOX 819020
DALLAS TX
75381-9020
US

V. Phone/Fax

Practice location:
  • Phone: 972-687-1877
  • Fax: 972-367-3434
Mailing address:
  • Phone: 972-687-1877
  • Fax: 972-367-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BILL EDWARDS
Title or Position: DIRECTOR OF SPORTS MEDICINE
Credential: ATC, MA
Phone: 270-745-6026