Healthcare Provider Details

I. General information

NPI: 1205939568
Provider Name (Legal Business Name): PEDIATRIC ANAESTHESIA ASSOCIATES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 E CHESTNUT ST KOSAIR CHILDRENS HOSPITAL
LOUISVILLE KY
40202-1821
US

IV. Provider business mailing address

DEPARTMENT 5090 PO BOX 740041
LOUISVILLE KY
40201-7441
US

V. Phone/Fax

Practice location:
  • Phone: 502-451-9949
  • Fax: 502-451-4553
Mailing address:
  • Phone: 502-451-9949
  • Fax: 502-451-4553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WALTER M ROSE
Title or Position: DIRECTOR
Credential: D.O.
Phone: 502-451-9949