Healthcare Provider Details

I. General information

NPI: 1538115621
Provider Name (Legal Business Name): DOUGLAS G IRWIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 MARIE LANGDON DR SUITE 2
MANCHESTER KY
40962-6353
US

IV. Provider business mailing address

509 MEMORIAL DRIVE SUITE 2
MANCHESTER KY
40962-6195
US

V. Phone/Fax

Practice location:
  • Phone: 606-599-9955
  • Fax: 606-599-9966
Mailing address:
  • Phone: 606-598-5104
  • Fax: 606-598-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number38637
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38637
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: