Provider Demographics
NPI:1063660405
Name:ERIC T. WOOTEN, D.O., PSC
Entity Type:Organization
Organization Name:ERIC T. WOOTEN, D.O., PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:T
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:270-842-1669
Mailing Address - Street 1:1325 ANDREA ST
Mailing Address - Street 2:STE. 209
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5852
Mailing Address - Country:US
Mailing Address - Phone:270-842-1669
Mailing Address - Fax:270-843-1911
Practice Address - Street 1:1325 ANDREA ST
Practice Address - Street 2:STE. 209
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5852
Practice Address - Country:US
Practice Address - Phone:270-842-1669
Practice Address - Fax:270-843-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty