Healthcare Provider Details

I. General information

NPI: 1487953311
Provider Name (Legal Business Name): UNIVERSITY PEDIATRIC GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 2ND ST STE 102
BOWLING GREEN KY
42101-1778
US

IV. Provider business mailing address

PO BOX 2469
LOUISVILLE KY
40201-2469
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-7670
  • Fax: 502-852-7743
Mailing address:
  • Phone: 502-852-8500
  • Fax: 502-852-8556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GERARD P RABALAIS
Title or Position: CHAIRMAN
Credential: MD
Phone: 502-852-8600