Healthcare Provider Details

I. General information

NPI: 1528058377
Provider Name (Legal Business Name): LOURDES MEDICAL PAVILION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 LAKESHORE DR
KUTTAWA KY
42055-6202
US

IV. Provider business mailing address

PO BOX 8329
PADUCAH KY
42002-8329
US

V. Phone/Fax

Practice location:
  • Phone: 270-388-4357
  • Fax:
Mailing address:
  • Phone: 270-441-4125
  • Fax: 270-441-4171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28168
License Number StateKY

VIII. Authorized Official

Name: MR. MARK THOMPSON
Title or Position: CFO
Credential:
Phone: 270-444-2117