Provider Demographics
NPI:1780841007
Name:WESLEY FAMILY MEDICAL PSC
Entity Type:Organization
Organization Name:WESLEY FAMILY MEDICAL PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-586-1969
Mailing Address - Street 1:PO BOX 1099
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42135-1099
Mailing Address - Country:US
Mailing Address - Phone:270-586-1969
Mailing Address - Fax:270-586-1914
Practice Address - Street 1:1100 BROOKHAVEN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2746
Practice Address - Country:US
Practice Address - Phone:270-586-1969
Practice Address - Fax:270-586-1914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
KY3006580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000569379OtherANTHEM BCBS
KY00705Medicare PIN