Basic Information
| Provider Information | |||||||||
| NPI: | 1730213406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICINE ASSOCIATES OF WESTERN KENTUCKY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 KENTUCKY DAM RD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420039472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708982444 | ||||||||
| FaxNumber: | 2708984753 | ||||||||
| Practice Location | |||||||||
| Address1: | 6035 KENTUCKY DAM RD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420039472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708982444 | ||||||||
| FaxNumber: | 2708984753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2708982444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65937138 | 05 | KY | MEDICAID |