Healthcare Provider Details

I. General information

NPI: 1376865972
Provider Name (Legal Business Name): PEARL GERIATRICS AND PALLIATIVE MEDICINE, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2010
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 37188
LOUISVILLE KY
40233-7188
US

V. Phone/Fax

Practice location:
  • Phone: 502-456-0494
  • Fax: 504-456-0496
Mailing address:
  • Phone: 502-456-0494
  • Fax: 502-456-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3006777
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39870
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OSAWARU JUDE OMORUYI
Title or Position: OWNER
Credential: M.D.
Phone: 502-456-0494