Provider Demographics
NPI:1114962867
Name:SOUTHERN KENTUCKY UROLOGY LLC
Entity Type:Organization
Organization Name:SOUTHERN KENTUCKY UROLOGY LLC
Other - Org Name:SOUTHERN KENTUCKY UROLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:1325 ANDREA ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5852
Mailing Address - Country:US
Mailing Address - Phone:270-796-9191
Mailing Address - Fax:
Practice Address - Street 1:1325 ANDREA ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5852
Practice Address - Country:US
Practice Address - Phone:270-796-9191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046326A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100003160Medicaid
KY=========OtherTAX ID
KY7100003160Medicaid