Healthcare Provider Details

I. General information

NPI: 1912992421
Provider Name (Legal Business Name): FOUR RIVERS INTERNAL MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 PARISA DR
PADUCAH KY
42003-4584
US

IV. Provider business mailing address

3131 PARISA DR
PADUCAH KY
42003-4584
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-8000
  • Fax: 270-444-8000
Mailing address:
  • Phone: 270-444-8000
  • Fax: 270-444-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number21063
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6224S
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5660P
License Number StateKY

VIII. Authorized Official

Name: DONNA K FORD
Title or Position: OFFICE MANAGER
Credential:
Phone: 270-444-8000