Healthcare Provider Details

I. General information

NPI: 1154394294
Provider Name (Legal Business Name): CARDIOLOGY ASSOCIATES OF SOUTHERN KENTUCKY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 GLENVIEW DR
GLASGOW KY
42141-3424
US

IV. Provider business mailing address

1004 GLENVIEW DR
GLASGOW KY
42141-3424
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-9611
  • Fax: 270-651-9298
Mailing address:
  • Phone: 270-651-9611
  • Fax: 270-651-9298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number18627
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMARA C. BROCK
Title or Position: BUSINESS MANAGER
Credential:
Phone: 270-651-9611