Basic Information
| Provider Information | |||||||||
| NPI: | 1396960233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN KENTUCKY ORTHOPAEDIC & NEUROSURGICAL ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 NATCHEZ TRACE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707827800 | ||||||||
| FaxNumber: | 2708430779 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 NATCHEZ TRACE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707827800 | ||||||||
| FaxNumber: | 2708430779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | BURGER | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | NETWORK ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2707827800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QX0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100241800 | 05 | KY | MEDICAID | 000000060685 | 01 | KY | ANTHEM GROUP | OTHER |