Provider Demographics
NPI:1083641039
Name:BIG SANDY UROLOGY PSC
Entity Type:Organization
Organization Name:BIG SANDY UROLOGY PSC
Other - Org Name:WILLIAM C. THORNDYKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:THORNDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:MDCM FRCS
Authorized Official - Phone:606-638-1311
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-0569
Mailing Address - Country:US
Mailing Address - Phone:606-638-1311
Mailing Address - Fax:606-638-3739
Practice Address - Street 1:2489 HWY 644
Practice Address - Street 2:SUITE 202
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230
Practice Address - Country:US
Practice Address - Phone:606-638-1311
Practice Address - Fax:606-638-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29406208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5188137OtherAETNA
WV0010829000Medicaid
KY000000051680OtherANTHEM
OH2764629Medicaid
KY65929366Medicaid
OH2764629Medicaid
KY65929366Medicaid
KYCE8713Medicare PIN