Provider Demographics
NPI:1790075273
Name:WESTERN KENTUCKY UNIVERSITY SPORTS MEDICINE
Entity Type:Organization
Organization Name:WESTERN KENTUCKY UNIVERSITY SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPORTS MEDICINE
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:ATC, MA
Authorized Official - Phone:270-745-6026
Mailing Address - Street 1:PO BOX 819020
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75381-9020
Mailing Address - Country:US
Mailing Address - Phone:972-687-1877
Mailing Address - Fax:972-367-3434
Practice Address - Street 1:1605 AVENUE OF CHAMPIONS
Practice Address - Street 2:RM 128
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-6412
Practice Address - Country:US
Practice Address - Phone:972-687-1877
Practice Address - Fax:972-367-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health