1851348338 NPI number — PEDIATRIC ASSOCIATES

Table of content: (NPI 1851348338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851348338 NPI number — PEDIATRIC ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ASSOCIATES
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:
PEDIATRIC ASSOCIATES OF PIKEVILLE, LLC
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:
1851348338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2748
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIKEVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41502-2748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-432-3221
Provider Business Mailing Address Fax Number:
606-437-0438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
156 ISLAND CREEK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-432-3221
Provider Business Practice Location Address Fax Number:
606-437-0438
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SO
Authorized Official First Name:
DJIEN
Authorized Official Middle Name:
HWAT
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
606-432-3221

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  42956 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: 900119 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 3006127 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 35001205 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18-3880 . This is a "RURAL HEALTH PALMETTO" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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