Provider Demographics
NPI:1144215591
Name:LOURDES MEDICAL PAVILION, LLC
Entity Type:Organization
Organization Name:LOURDES MEDICAL PAVILION, LLC
Other - Org Name:PADUCAH DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:G
Authorized Official - Last Name:DYCUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-441-4125
Mailing Address - Street 1:225 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7914
Mailing Address - Country:US
Mailing Address - Phone:270-441-4100
Mailing Address - Fax:270-441-4171
Practice Address - Street 1:225 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7914
Practice Address - Country:US
Practice Address - Phone:270-441-4100
Practice Address - Fax:270-441-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY730026293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9360601Medicare ID - Type Unspecified