Provider Demographics
NPI:1760547103
Name:C FRED GOTT M.D.
Entity Type:Organization
Organization Name:C FRED GOTT M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BEDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-782-7464
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-1078
Mailing Address - Country:US
Mailing Address - Phone:270-782-7464
Mailing Address - Fax:270-782-8025
Practice Address - Street 1:191 W PROFESSIONAL PARK CT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3230
Practice Address - Country:US
Practice Address - Phone:270-782-7464
Practice Address - Fax:270-782-8025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20987261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========OtherFEIN
KY=========OtherFEIN