1790075273 NPI number — WESTERN KENTUCKY UNIVERSITY SPORTS MEDICINE

Table of content: (NPI 1790075273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790075273 NPI number — WESTERN KENTUCKY UNIVERSITY SPORTS MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN KENTUCKY UNIVERSITY SPORTS MEDICINE
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:
1790075273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 819020
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75381-9020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-687-1877
Provider Business Mailing Address Fax Number:
972-367-3434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 AVENUE OF CHAMPIONS
Provider Second Line Business Practice Location Address:
RM 128
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42101-6412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-687-1877
Provider Business Practice Location Address Fax Number:
972-367-3434
Provider Enumeration Date:
04/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
BILL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF SPORTS MEDICINE
Authorized Official Telephone Number:
270-745-6026

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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