MEDICARE: ALL-STAR PEDIATRICS PSC

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	2080A0000X	Pediatric Adolescent Medicine Physician	37862	KY
2	2080A0000X	Pediatric Adolescent Medicine Physician	27333	KY

General Provider Information

NPI Number	:	1689774994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALL-STAR PEDIATRICS PSC

Provider Business Mailing Address
First Line	:	6425 BARDSTOWN RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-3040
Country	:	US
Telephone Number	:	502-762-0498
Fax Number	:	502-762-0469

Provider Business Practice Location Address
First Line	:	6425 BARDSTOWN RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-3040
Country	:	US
Telephone Number	:	502-762-0498
Fax Number	:	502-762-0469

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. JEAN L GEE
Credential	:
Telephone Number	:	502-762-0498

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	06/30/2008

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Practice Location Address:

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1124040258 — DR. KATHY T. RAGAN D.M.D.
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Practice Location Address:

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Directions to “ALL-STAR PEDIATRICS PSC ” Practice Location

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