Healthcare Provider Details

I. General information

NPI: 1922155407
Provider Name (Legal Business Name): WESTSIDE PEDIATRICS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 ALEXANDRIA DR
LEXINGTON KY
40504-3149
US

IV. Provider business mailing address

1701 ALEXANDRIA DR
LEXINGTON KY
40504-3149
US

V. Phone/Fax

Practice location:
  • Phone: 859-277-3490
  • Fax: 859-278-5014
Mailing address:
  • Phone: 859-277-3490
  • Fax: 859-278-5014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18125
License Number StateKY

VIII. Authorized Official

Name: DR. REBECCA G BOSOMWORTH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 859-277-3490