Basic Information
| Provider Information | |||||||||
| NPI: | 1528058377 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOURDES MEDICAL PAVILION, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LYON COUNTY FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8329 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420028329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414125 | ||||||||
| FaxNumber: | 2704414171 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | KUTTAWA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420556202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703884357 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2704442117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 28168 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.