MEDICARE: UNIVERSITY PEDIATRIC GASTROENTEROLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0206X	Pediatric Gastroenterology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568790277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY PEDIATRIC GASTROENTEROLOGY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2469
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40201-2469
Country	:	US
Telephone Number	:	502-852-8500
Fax Number	:	502-852-8556

Provider Business Practice Location Address
First Line	:	9700 PARK PLAZA AVENUE
Second Line	:	SUITE 110
City	:	LOUISVILLE
State	:	KY
Zip	:	40241-2286
Country	:	US
Telephone Number	:	502-852-7670
Fax Number	:	502-852-7743

Authorized Official
Title or Position	:	CHAIRMAN
Name	:	DR. GERARD P. RABALAIS
Credential	:	MD
Telephone Number	:	502-852-8600

Provider Enumeration Date	:	11/19/2009
Last Update Date	:	11/19/2009

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Directions to “UNIVERSITY PEDIATRIC GASTROENTEROLOGY, LLC ” Practice Location

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