Healthcare Provider Details

I. General information

NPI: 1104348622
Provider Name (Legal Business Name): VILLAGEMD KENTUCKY, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S 12TH ST
MURRAY KY
42071
US

IV. Provider business mailing address

125 S CLARK ST STE 900
CHICAGO IL
60603-5200
US

V. Phone/Fax

Practice location:
  • Phone: 270-759-9200
  • Fax: 270-759-8368
Mailing address:
  • Phone: 312-465-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberTP057
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberTP057
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTP057
License Number StateKY

VIII. Authorized Official

Name: WENDY LEE RUBAS
Title or Position: GENERAL COUNSEL
Credential:
Phone: 312-465-7898