Healthcare Provider Details

I. General information

NPI: 1568503993
Provider Name (Legal Business Name): EAST TENNESSEE WOUND CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 NORTON HEALTHCARE BLVD SUITE 101
LOUISVILLE KY
40241-2845
US

IV. Provider business mailing address

PO BOX 8180
LOUISVILLE KY
40257-8180
US

V. Phone/Fax

Practice location:
  • Phone: 502-446-6160
  • Fax:
Mailing address:
  • Phone: 502-753-0680
  • Fax: 502-753-0687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number21368
License Number StateKY

VIII. Authorized Official

Name: DR. CARY THOMAS KIRK
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 502-930-9861