Provider Demographics
NPI:1104348622
Name:VILLAGEMD KENTUCKY, PSC
Entity type:Organization
Organization Name:VILLAGEMD KENTUCKY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RUBAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-465-7898
Mailing Address - Street 1:125 S CLARK ST STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5200
Mailing Address - Country:US
Mailing Address - Phone:312-465-7900
Mailing Address - Fax:
Practice Address - Street 1:1000 S 12TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071
Practice Address - Country:US
Practice Address - Phone:270-759-9200
Practice Address - Fax:270-759-8368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP057207RE0101X, 225100000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty