Healthcare Provider Details

I. General information

NPI: 1487600615
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 N MAIN ST PEDIATRIC ASSOCIATES
HAZARD KY
41701-1278
US

IV. Provider business mailing address

PO BOX 2748 PEDIATRIC ASSOCIATES
PIKEVILLE KY
41502-2748
US

V. Phone/Fax

Practice location:
  • Phone: 606-487-8300
  • Fax: 606-436-9953
Mailing address:
  • Phone: 606-432-3221
  • Fax: 606-437-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number900138
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3006127
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DJIEN HWAT SO
Title or Position: ADMINISTRATOR
Credential:
Phone: 606-487-8300