Healthcare Provider Details

I. General information

NPI: 1083607204
Provider Name (Legal Business Name): INFECTIOUS DISEASES ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 BROADWAY ST
PADUCAH KY
42001-7105
US

IV. Provider business mailing address

1903 BROADWAY ST
PADUCAH KY
42001-7105
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-9889
  • Fax: 270-444-9291
Mailing address:
  • Phone: 270-444-9889
  • Fax: 270-444-9291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MARISSA WELLS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 270-444-9889