Provider Demographics
NPI:1760717516
Name:PAMELA K HARSTON, MD, PLC
Entity Type:Organization
Organization Name:PAMELA K HARSTON, MD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:HARSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-904-6160
Mailing Address - Street 1:1890 LYDA AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5829
Mailing Address - Country:US
Mailing Address - Phone:270-904-6160
Mailing Address - Fax:270-904-6165
Practice Address - Street 1:1890 LYDA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5829
Practice Address - Country:US
Practice Address - Phone:270-904-6160
Practice Address - Fax:270-904-6165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY259362081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64259369Medicaid
KY64259369Medicaid
KY6373990001Medicare NSC
KY01134Medicare PIN