Healthcare Provider Details

I. General information

NPI: 1265496483
Provider Name (Legal Business Name): CENTRAL CARDIOLOGY ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 WOODLAND DRIVE SUITE A
ELIZABETHTOWN KY
42701
US

IV. Provider business mailing address

1324 WOODLAND DRIVE SUITE A
ELIZABETHTOWN KY
42701
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-5921
  • Fax: 270-769-0000
Mailing address:
  • Phone: 270-765-5921
  • Fax: 270-769-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELISSA PRUITT
Title or Position: ADMINISTRATOR
Credential:
Phone: 270-765-5921