Healthcare Provider Details

I. General information

NPI: 1497088090
Provider Name (Legal Business Name): HENDERSON PEDIATRICS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 N ELM ST
HENDERSON KY
42420-2712
US

IV. Provider business mailing address

1035 N ELM ST
HENDERSON KY
42420-2712
US

V. Phone/Fax

Practice location:
  • Phone: 270-827-4596
  • Fax:
Mailing address:
  • Phone: 270-827-4596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number40961
License Number StateKY

VIII. Authorized Official

Name: KIMBERLY K RUDD
Title or Position: BILLING SPECIALIST
Credential:
Phone: 270-827-4596