Provider Demographics
NPI:1154486942
Name:WEST KENTUCKY GYNECOLOGY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:WEST KENTUCKY GYNECOLOGY ASSOCIATES PLLC
Other - Org Name:GYNECOLOGY ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-442-7181
Mailing Address - Street 1:423 SOUTH 28TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3865
Mailing Address - Country:US
Mailing Address - Phone:270-442-7181
Mailing Address - Fax:270-442-0113
Practice Address - Street 1:423 SOUTH 28TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3865
Practice Address - Country:US
Practice Address - Phone:270-442-7181
Practice Address - Fax:270-442-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35692207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64013931Medicaid
0660501Medicare ID - Type Unspecified
C02788Medicare UPIN