Provider Demographics
NPI:1093063406
Name:WESTERN BAPTIST MEDICAL VENTURES INC
Entity Type:Organization
Organization Name:WESTERN BAPTIST MEDICAL VENTURES INC
Other - Org Name:BAPTIST HEALTH PRIME CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHYSICIAN INTEGRATION
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-575-8362
Mailing Address - Street 1:PO BOX 7309
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7309
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:2601 KENTUCKY AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3817
Practice Address - Country:US
Practice Address - Phone:270-443-4311
Practice Address - Fax:270-443-4145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN BAPTIST MEDICAL VENTURES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-16
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Q00000X, 261QP2300X
KYPA588363AM0700X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00211Medicare PIN