Healthcare Provider Details

I. General information

NPI: 1093063406
Provider Name (Legal Business Name): WESTERN BAPTIST MEDICAL VENTURES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 KENTUCKY AVE SUITE 103
PADUCAH KY
42003-3817
US

IV. Provider business mailing address

PO BOX 7309
PADUCAH KY
42002-7309
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-4311
  • Fax: 270-443-4145
Mailing address:
  • Phone: 270-744-9600
  • Fax: 270-744-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA588
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateKY

VIII. Authorized Official

Name: PATRICIA HARROD
Title or Position: DIRECTOR OF PHYSICIAN INTEGRATION
Credential:
Phone: 270-575-8362