Basic Information
| Provider Information | |||||||||
| NPI: | 1497750194 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KENTUCKY EMERGENCY SERVICES P.S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004768646 | ||||||||
| FaxNumber: | 9193823210 | ||||||||
| Practice Location | |||||||||
| Address1: | 727 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400651660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026474347 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WETHERTON | ||||||||
| AuthorizedOfficialFirstName: | BRENDEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5024544274 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000060164 | 01 | KY | BCBS 12 DIGIT GROUP # | OTHER | 1172544 | 01 | KY | PASSPORT HEALTH GROUP # | OTHER | 65929739 | 05 | KY | MEDICAID |