Healthcare Provider Details

I. General information

NPI: 1902342751
Provider Name (Legal Business Name): KENTUCKY PAIN MANAGEMENT PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 GOLDSMITH LN STE 117
LOUISVILLE KY
40218-3176
US

IV. Provider business mailing address

1939 GOLDSMITH LN STE 117
LOUISVILLE KY
40218-3176
US

V. Phone/Fax

Practice location:
  • Phone: 502-447-2222
  • Fax: 502-448-2215
Mailing address:
  • Phone: 502-447-2222
  • Fax: 502-448-2215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number34304
License Number StateKY

VIII. Authorized Official

Name: DR. ROBERT W BYRD
Title or Position: OWNER
Credential: M.D.
Phone: 502-447-2222