Healthcare Provider Details

I. General information

NPI: 1205346210
Provider Name (Legal Business Name): INTERVENTIONAL PAIN SPECIALISTS OF BOWLING GREEN, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 S MAIN ST STE 7
FRANKLIN KY
42134-2371
US

IV. Provider business mailing address

165 NATCHEZ TRACE AVE STE 205
BOWLING GREEN KY
42103-7947
US

V. Phone/Fax

Practice location:
  • Phone: 270-745-7246
  • Fax: 270-282-2027
Mailing address:
  • Phone: 270-745-7246
  • Fax: 270-282-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT KEITH NORMAN
Title or Position: VP
Credential: CRNA
Phone: 270-393-1912