Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 001533 | KY |
N | 2251H1200X | Hand | 10011030054 | KY |
NPI | 1053300277 |
---|---|
Provider Name | Forrest L (ben) Waide |
First Address | Madisonville, KY 42431-7700 |
Second Address | Madisonville, KY 42431-7700 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2005 |
Last Update Date | 27/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000477215 | ANTHEM BCBS FACET # (01) | KY |