=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760547103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C FRED GOTT M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 06/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 191 W PROFESSIONAL PARK CT
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-3230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-782-7464
-----------------------------------------------------
Fax | 270-782-8025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1078
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42102-1078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-782-7464
-----------------------------------------------------
Fax | 270-782-8025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | ROBERT BEDARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-782-7464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 20987
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------