Healthcare Provider Details

I. General information

NPI: 1235131533
Provider Name (Legal Business Name): WESTERN KENTUCKY UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 COLLEGE HEIGHTS BLVD #8400
BOWLING GREEN KY
42101-1041
US

IV. Provider business mailing address

1906 COLLEGE HEIGHTS BLVD #8400
BOWLING GREEN KY
42101-1041
US

V. Phone/Fax

Practice location:
  • Phone: 270-745-5641
  • Fax: 270-745-2449
Mailing address:
  • Phone: 270-745-5641
  • Fax: 270-745-2449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1041583
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30097
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36233
License Number StateKY

VIII. Authorized Official

Name: MRS. LINDA HEADY
Title or Position: INSURANCE & BILLING COORDINATOR
Credential:
Phone: 270-745-5034