=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962070334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PADUCAH PLASTIC AND RECONSTRUCTIVE SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2021
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2605 KENTUCKY AVE STE 100
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-709-1984
-----------------------------------------------------
Fax | 270-933-1047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 KENTUCKY AVE STE 100
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-709-1984
-----------------------------------------------------
Fax | 270-933-1047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/MANAGER
-----------------------------------------------------
Name | DR. DANIEL E VERBIST
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 270-709-1984
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0122X
-----------------------------------------------------
Taxonomy Name | Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------