Basic Information
| Provider Information | |||||||||
| NPI: | 1891806899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN KENTUCKY CARDIOLOGY CONSULTANTS, PSC | ||||||||
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| OtherOrganizationName: | THE HEART GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7648 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420027648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004672392 | ||||||||
| FaxNumber: | 8124716650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 KENTUCKY AVE | ||||||||
| Address2: | DOB 1 SUITE 301 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705753113 | ||||||||
| FaxNumber: | 2705753135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | GWINN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2704150361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261Q00000X | KY | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 4406729 | 05 | TN | MEDICAID | 0855626 | 01 | KY | UMW PROV. GROUP NUMBER | OTHER | 2152 | 01 | KY | BLUE SHIELD | OTHER |