Provider Demographics
NPI:1669626701
Name:KEN EMBRY M.D.
Entity Type:Organization
Organization Name:KEN EMBRY M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EMBRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-843-6391
Mailing Address - Street 1:1733 CAMPUS PLAZA CT STE 5
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2996
Mailing Address - Country:US
Mailing Address - Phone:270-843-6391
Mailing Address - Fax:270-782-6766
Practice Address - Street 1:1733 CAMPUS PLAZA CT STE 5
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2996
Practice Address - Country:US
Practice Address - Phone:270-843-6391
Practice Address - Fax:270-782-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17296261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
C68429Medicare UPIN