Healthcare Provider Details

I. General information

NPI: 1073703054
Provider Name (Legal Business Name): WESTERN BAPTIST MEDICAL VENTURES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 KENTUCKY AVE
PADUCAH KY
42003-3813
US

IV. Provider business mailing address

2501 KENTUCKY AVE
PADUCAH KY
42003-3813
US

V. Phone/Fax

Practice location:
  • Phone: 270-575-2101
  • Fax: 270-575-2905
Mailing address:
  • Phone: 270-575-2101
  • Fax: 270-575-2905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LARRY BARTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 270-575-2101