Basic Information
| Provider Information | |||||||||
| NPI: | 1437340346 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAYNESBURG CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 330 | ||||||||
| Address2: | |||||||||
| City: | STANFORD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404840330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063796646 | ||||||||
| FaxNumber: | 6063795707 | ||||||||
| Practice Location | |||||||||
| Address1: | 14098 KY HIGHWAY 27 SOUTH | ||||||||
| Address2: | |||||||||
| City: | WAYNESBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063796646 | ||||||||
| FaxNumber: | 6063795707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 08/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | SIMS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | DUVALL | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6063651547 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363AM0700X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.