Healthcare Provider Details

I. General information

NPI: 1093701823
Provider Name (Legal Business Name): JACKSON PURCHASE ER PHYSICIANS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 LONE OAK RD
PADUCAH KY
42003-7901
US

IV. Provider business mailing address

PO BOX 78
EVANSVILLE IN
47701-0078
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-0878
  • Fax: 270-444-6252
Mailing address:
  • Phone: 800-467-2394
  • Fax: 270-444-6252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN W VANDERBOEGH
Title or Position: PRESIDENT
Credential: MD
Phone: 270-444-0878