Provider Demographics
NPI:1295777084
Name:WESTERN KENTUCKY GASTROENTEROLOGY, LLC
Entity type:Organization
Organization Name:WESTERN KENTUCKY GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:996 WILKINSON TRCE
Mailing Address - Street 2:SUITE A-10
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-3407
Mailing Address - Country:US
Mailing Address - Phone:270-393-9829
Mailing Address - Fax:270-393-9830
Practice Address - Street 1:996 WILKINSON TRCE
Practice Address - Street 2:SUITE A-10
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3407
Practice Address - Country:US
Practice Address - Phone:270-393-9829
Practice Address - Fax:270-393-9830
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL CORP., LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-13
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65944050Medicaid
KY9799Medicare PIN