Provider Demographics
NPI:1316017080
Name:WESTERN BAPTIST MEDICAL VENTURES, INC.
Entity Type:Organization
Organization Name:WESTERN BAPTIST MEDICAL VENTURES, INC.
Other - Org Name:PADUCAH NEUROSURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-575-2139
Mailing Address - Street 1:PO BOX 7909
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7909
Mailing Address - Country:US
Mailing Address - Phone:270-575-2139
Mailing Address - Fax:270-575-2634
Practice Address - Street 1:2603 KENTUCKY AVE STE 404
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3830
Practice Address - Country:US
Practice Address - Phone:270-443-6472
Practice Address - Fax:270-442-1649
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN BAPTIST MEDICAL VENTURES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-09
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207T00000X, 363AS0400X
KY4059P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000521597OtherANTHEM BCBS
KYDF7549OtherRAILROAD MEDICARE
KY65945867Medicaid
KY7100002230Medicaid
KY7100002230Medicaid