Provider Demographics
NPI:1891806899
Name:WESTERN KENTUCKY CARDIOLOGY CONSULTANTS, PSC
Entity Type:Organization
Organization Name:WESTERN KENTUCKY CARDIOLOGY CONSULTANTS, PSC
Other - Org Name:THE HEART GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:GWINN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:270-415-0361
Mailing Address - Street 1:PO BOX 7648
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7648
Mailing Address - Country:US
Mailing Address - Phone:800-467-2392
Mailing Address - Fax:812-471-6650
Practice Address - Street 1:2601 KENTUCKY AVE
Practice Address - Street 2:DOB 1 SUITE 301
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3817
Practice Address - Country:US
Practice Address - Phone:270-575-3113
Practice Address - Fax:270-575-3135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261Q00000X
363AM0700X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4406729Medicaid
KY0855626OtherUMW PROV. GROUP NUMBER
KY2152OtherBLUE SHIELD
KY2152OtherBLUE SHIELD
KY=========003OtherCHAMPUS GROUP NUMBER