Provider Demographics
NPI:1447501184
Name:PENNYRILE GENERAL & WEIGHT LOSS SURGERY PLLC
Entity type:Organization
Organization Name:PENNYRILE GENERAL & WEIGHT LOSS SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GERAME
Authorized Official - Middle Name:T
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-887-0278
Mailing Address - Street 1:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-2400
Mailing Address - Country:US
Mailing Address - Phone:270-632-4555
Mailing Address - Fax:270-632-4556
Practice Address - Street 1:320 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1965
Practice Address - Country:US
Practice Address - Phone:270-632-4555
Practice Address - Fax:270-632-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100223340Medicaid
K060310Medicare PIN