Basic Information
| Provider Information | |||||||||
| NPI: | 1376533992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALE | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707802497 | ||||||||
| FaxNumber: | 2707833750 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 N RACE ST | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706295111 | ||||||||
| FaxNumber: | 2706295115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20062 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64200629 | 05 | KY | MEDICAID |