Provider Demographics
NPI:1790893964
Name:NEUROLOGY GROUP OF PADUCAH, PLLC
Entity Type:Organization
Organization Name:NEUROLOGY GROUP OF PADUCAH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOELTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-443-2830
Mailing Address - Street 1:2603 KENTUCKY AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3814
Mailing Address - Country:US
Mailing Address - Phone:270-443-2830
Mailing Address - Fax:270-443-7108
Practice Address - Street 1:2603 KENTUCKY AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3814
Practice Address - Country:US
Practice Address - Phone:270-443-2830
Practice Address - Fax:270-443-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY877432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1391OtherNEUROLOGY GROUP PTAN
KY65939647Medicaid
KY7698Medicare PIN
KYDA1746Medicare PIN
IL1391001Medicare PIN