Healthcare Provider Details

I. General information

NPI: 1316017080
Provider Name (Legal Business Name): WESTERN BAPTIST MEDICAL VENTURES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 KENTUCKY AVE STE 404
PADUCAH KY
42003-3830
US

IV. Provider business mailing address

PO BOX 7909
PADUCAH KY
42002-7909
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-6472
  • Fax: 270-442-1649
Mailing address:
  • Phone: 270-575-2139
  • Fax: 270-575-2634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4059P
License Number StateKY

VIII. Authorized Official

Name: LARRY BARTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 270-575-2139