Provider Demographics
NPI:1902342751
Name:KENTUCKY PAIN MANAGEMENT PSC
Entity Type:Organization
Organization Name:KENTUCKY PAIN MANAGEMENT PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-447-2222
Mailing Address - Street 1:1939 GOLDSMITH LN STE 117
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-3176
Mailing Address - Country:US
Mailing Address - Phone:502-447-2222
Mailing Address - Fax:502-448-2215
Practice Address - Street 1:1939 GOLDSMITH LN STE 117
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3176
Practice Address - Country:US
Practice Address - Phone:502-447-2222
Practice Address - Fax:502-448-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34304208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty