Basic Information
| Provider Information | |||||||||
| NPI: | 1144295882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAM G DEVINE M.D. PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1079 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424191079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708270353 | ||||||||
| FaxNumber: | 2708274966 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424202783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708277700 | ||||||||
| FaxNumber: | 2708274966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | DEVINE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2708270353 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 35368 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64003551 | 05 | KY | MEDICAID | 000000325047 | 01 | KY | ANTHEM BC & BS | OTHER |