Basic Information
| Provider Information | |||||||||
| NPI: | 1528156866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST KENTUCKY RHEUMATOLOGY,PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 AUGUSTA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420035584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705340046 | ||||||||
| FaxNumber: | 2705340048 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 AUGUSTA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420035584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705340046 | ||||||||
| FaxNumber: | 2705340048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 04/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAILEY | ||||||||
| AuthorizedOfficialFirstName: | BILLY | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2705340046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 26804 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 145768 | 01 | HEALTHLINK | OTHER | 000000049267 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER | 029602 | 01 | HEALTH ALLIANCE | OTHER | 3145428 | 01 | TN | BLUE CROSS/SHIELD TN | OTHER |