Provider Demographics
NPI:1023280518
Name:WESTLAKE PRIMARY CARE OF RUSSELL COUNTY MEDICAL GROUP
Entity type:Organization
Organization Name:WESTLAKE PRIMARY CARE OF RUSSELL COUNTY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:A
Authorized Official - Last Name:TUNGATE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:270-384-4753
Mailing Address - Street 1:2465 LAKEWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642
Mailing Address - Country:US
Mailing Address - Phone:270-858-3636
Mailing Address - Fax:270-858-3660
Practice Address - Street 1:2465 LAKEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642
Practice Address - Country:US
Practice Address - Phone:270-858-3636
Practice Address - Fax:270-858-3660
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADAIR COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY282352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6592976200Medicaid