Basic Information
| Provider Information | |||||||||
| NPI: | 1225287154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLASGOW URGENT CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREENWOOD URGENT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4863B SCOTTSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421047855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708435662 | ||||||||
| FaxNumber: | 2708435614 | ||||||||
| Practice Location | |||||||||
| Address1: | 4863B SCOTTSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421047855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708435662 | ||||||||
| FaxNumber: | 2708435614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2008 | ||||||||
| LastUpdateDate: | 09/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | MANION | ||||||||
| AuthorizedOfficialFirstName: | KENNY | ||||||||
| AuthorizedOfficialMiddleName: | JOE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2706517796 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 65933863 | 05 | KY | MEDICAID |