1134320492 NPI number — MEDICAL SPECIALISTS OF CENTRAL KENTUCKY, P.S.C.

Table of content: (NPI 1134320492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134320492 NPI number — MEDICAL SPECIALISTS OF CENTRAL KENTUCKY, P.S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL SPECIALISTS OF CENTRAL KENTUCKY, P.S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134320492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51726
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42102-6726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-746-0440
Provider Business Mailing Address Fax Number:
270-746-0882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 PARK ST
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42101-1784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-746-0440
Provider Business Practice Location Address Fax Number:
270-746-0882
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHADOWEN
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
OWNER, PRESIDENT
Authorized Official Telephone Number:
270-746-0440

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  26582 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000051271 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65935504 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10806088 . This is a "CAQH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CC3484 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1255438420 . This is a "NPI FOR DR. R. SHADOWEN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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