Healthcare Provider Details

I. General information

NPI: 1568699478
Provider Name (Legal Business Name): WESTERN BAPTIST MEDICAL VENTURES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 KENTUCKY AVE SUITE 304
PADUCAH KY
42003-3814
US

IV. Provider business mailing address

PO BOX 7309
PADUCAH KY
42002-7309
US

V. Phone/Fax

Practice location:
  • Phone: 270-415-4800
  • Fax: 270-415-4801
Mailing address:
  • Phone: 270-744-9600
  • Fax: 270-744-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number44538
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number3006220
License Number StateKY

VIII. Authorized Official

Name: JENNIFER A TOWNSEND
Title or Position: REGIONAL EXECUTIVE DIR OF OPERATION
Credential:
Phone: 270-415-7646