Healthcare Provider Details

I. General information

NPI: 1033270434
Provider Name (Legal Business Name): PEDIATRIC PULMONARY MEDICINE, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 EAST GRAY STREET SUITE 270
LOUISVILLE KY
40202
US

IV. Provider business mailing address

6801 DIXIE HIGHWAY SUITE 130
LOUISVILLE KY
40258
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-3772
  • Fax: 502-852-4051
Mailing address:
  • Phone: 502-451-5855
  • Fax: 502-479-1409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number25574
License Number StateKY

VIII. Authorized Official

Name: NEMR EID
Title or Position: OWNER OF PRACTICE
Credential: MD
Phone: 502-852-3772