Healthcare Provider Details

I. General information

NPI: 1689774994
Provider Name (Legal Business Name): ALL-STAR PEDIATRICS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6425 BARDSTOWN RD
LOUISVILLE KY
40291-3040
US

IV. Provider business mailing address

6425 BARDSTOWN RD
LOUISVILLE KY
40291-3040
US

V. Phone/Fax

Practice location:
  • Phone: 502-762-0498
  • Fax: 502-762-0469
Mailing address:
  • Phone: 502-762-0498
  • Fax: 502-762-0469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number37862
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number27333
License Number StateKY

VIII. Authorized Official

Name: MS. JEAN L GEE
Title or Position: OFFICE MANAGER
Credential:
Phone: 502-762-0498