Healthcare Provider Details

I. General information

NPI: 1508204223
Provider Name (Legal Business Name): CLARK REGIONAL PHYSICIAN PRACTICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 HOSPITAL DR SUITE 300A
WINCHESTER KY
40391-7676
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 859-737-6555
  • Fax: 859-737-6650
Mailing address:
  • Phone: 615-920-7905
  • Fax: 615-920-8935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SARA MILLER
Title or Position: DIRECTOR
Credential:
Phone: 615-202-9581