Healthcare Provider Details

I. General information

NPI: 1699792465
Provider Name (Legal Business Name): EAST LOUISVILLE PEDIATRICS, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4171 WESTPORT RD
LOUISVILLE KY
40207-2739
US

IV. Provider business mailing address

4171 WESTPORT RD
LOUISVILLE KY
40207-2739
US

V. Phone/Fax

Practice location:
  • Phone: 502-896-8868
  • Fax: 502-895-6278
Mailing address:
  • Phone: 502-721-0012
  • Fax: 502-895-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KAYLA WEST
Title or Position: OFFICE MANAGER
Credential:
Phone: 502-721-0012