Healthcare Provider Details

I. General information

NPI: 1891806899
Provider Name (Legal Business Name): WESTERN KENTUCKY CARDIOLOGY CONSULTANTS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 KENTUCKY AVE DOB 1 SUITE 301
PADUCAH KY
42003-3817
US

IV. Provider business mailing address

PO BOX 7648
PADUCAH KY
42002-7648
US

V. Phone/Fax

Practice location:
  • Phone: 270-575-3113
  • Fax: 270-575-3135
Mailing address:
  • Phone: 800-467-2392
  • Fax: 812-471-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES S. GWINN JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 270-415-0361