Healthcare Provider Details

I. General information

NPI: 1669841631
Provider Name (Legal Business Name): PEARL MEDICAL PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 BUECHEL AVE STE 105
LOUISVILLE KY
40218-2672
US

IV. Provider business mailing address

PO BOX 35294
LOUISVILLE KY
40232-5294
US

V. Phone/Fax

Practice location:
  • Phone: 502-456-0494
  • Fax: 502-456-0496
Mailing address:
  • Phone: 502-456-0494
  • Fax: 502-456-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OSAWARU JUDE OMORUYI
Title or Position: OWNER
Credential: MD
Phone: 502-456-0494