Basic Information
| Provider Information | |||||||||
| NPI: | 1780841007 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESLEY FAMILY MEDICAL PSC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1099 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421351099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705861969 | ||||||||
| FaxNumber: | 2705861914 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 BROOKHAVEN RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421342746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705861969 | ||||||||
| FaxNumber: | 2705861914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WESLEY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 2705861969 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3006580 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000569379 | 01 | ANTHEM BCBS | OTHER |