Provider Demographics
NPI:1053341339
Name:PARK STREET PARTNERS, L.L.P.
Entity type:Organization
Organization Name:PARK STREET PARTNERS, L.L.P.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-745-1536
Mailing Address - Street 1:PO BOX 3240
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-3240
Mailing Address - Country:US
Mailing Address - Phone:270-745-1100
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:1225 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2477
Practice Address - Country:US
Practice Address - Phone:270-781-3910
Practice Address - Fax:270-842-7177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65900813Medicaid
KY78900982Medicaid
KY65900813Medicaid