Healthcare Provider Details

I. General information

NPI: 1649577362
Provider Name (Legal Business Name): UNIVERSITY PEDIATRIC PULMONARY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 PARK PLAZA AVE STE 110
LOUISVILLE KY
40241-2286
US

IV. Provider business mailing address

PO BOX 2469
LOUISVILLE KY
40201-2469
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-8830
  • Fax: 502-629-7540
Mailing address:
  • Phone: 502-852-8500
  • Fax: 502-852-8556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. GERARD P. RABALAIS
Title or Position: CHAIRMAN
Credential: MD
Phone: 502-852-8600