Healthcare Provider Details

I. General information

NPI: 1750729133
Provider Name (Legal Business Name): WESTERN BAPTIST MEDICAL VENTURES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KIANA CT
PADUCAH KY
42001-6787
US

IV. Provider business mailing address

PO BOX 7309
PADUCAH KY
42002-7309
US

V. Phone/Fax

Practice location:
  • Phone: 270-554-0011
  • Fax: 270-554-6540
Mailing address:
  • Phone: 270-744-9600
  • Fax: 270-744-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number17391
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3004564
License Number StateKY

VIII. Authorized Official

Name: PATRICIA K HARROD
Title or Position: DIRECTOR OF PHYSICIAN INTEGRATION
Credential:
Phone: 270-575-8362