Provider Demographics
NPI:1568503993
Name:EAST TENNESSEE WOUND CARE PC
Entity Type:Organization
Organization Name:EAST TENNESSEE WOUND CARE PC
Other - Org Name:ROLYN PSC
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-930-9861
Mailing Address - Street 1:PO BOX 8180
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40257-8180
Mailing Address - Country:US
Mailing Address - Phone:502-753-0680
Mailing Address - Fax:502-753-0687
Practice Address - Street 1:4950 NORTON HEALTHCARE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2845
Practice Address - Country:US
Practice Address - Phone:502-446-6160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY213682083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2789407000OtherPASSPORT ADVANTAGE
KYDF7517OtherRAILROAD MEDICARE
KY000000487847OtherANTHEM BLUE CROSS BLUE SHIELD
IN200828020AMedicaid
KY50012967OtherPASSPORT HEALTH PLANS
KY00167Medicare PIN