Healthcare Provider Details

I. General information

NPI: 1821280967
Provider Name (Legal Business Name): WESTERN BAPTIST MEDICAL VENTURES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 KENTUCKY AVE SUITE 103
PADUCAH KY
42003-3814
US

IV. Provider business mailing address

PO BOX 7309
PADUCAH KY
42002-7309
US

V. Phone/Fax

Practice location:
  • Phone: 270-415-7724
  • Fax: 270-415-7727
Mailing address:
  • Phone: 270-744-9600
  • Fax: 270-744-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY O BARTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 270-575-2100