1669415493 NPI number — MERCER PEDIATRICS PSC

Table of content: (NPI 1669415493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669415493 NPI number — MERCER PEDIATRICS PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCER PEDIATRICS PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HAGGIN PRIMARY CARE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669415493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 364
Provider Second Line Business Mailing Address:
466 LINDEN AVENUE
Provider Business Mailing Address City Name:
HARRODSBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40330-0364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-734-5123
Provider Business Mailing Address Fax Number:
859-734-0664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
466 LINDEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRODSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40330-1841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-734-5123
Provider Business Practice Location Address Fax Number:
859-734-0664
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
859-734-5123

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  25108 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 65929507 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 610510934 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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