Provider Demographics
NPI:1164428256
Name:WINDING RIVER HEALTH CARE PSC
Entity Type:Organization
Organization Name:WINDING RIVER HEALTH CARE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:M
Authorized Official - Last Name:WIELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-683-3073
Mailing Address - Street 1:815 E PARRISH AVE
Mailing Address - Street 2:STE 420
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3222
Mailing Address - Country:US
Mailing Address - Phone:270-852-6600
Mailing Address - Fax:270-852-6611
Practice Address - Street 1:815 E PARRISH AVE
Practice Address - Street 2:STE 420
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3222
Practice Address - Country:US
Practice Address - Phone:270-852-6600
Practice Address - Fax:270-852-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2020-08-22
Deactivation Date:2007-03-14
Deactivation Code:
Reactivation Date:2007-05-09
Provider Licenses
StateLicense IDTaxonomies
KY34921207R00000X
KY34118207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65933574Medicaid
KY6682Medicare ID - Type Unspecified