Healthcare Provider Details

I. General information

NPI: 1376901868
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF LOUISVILLE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2016
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5721 BARDSTOWN RD
LOUISVILLE KY
40291-1913
US

IV. Provider business mailing address

5721 BARDSTOWN RD
LOUISVILLE KY
40291-1913
US

V. Phone/Fax

Practice location:
  • Phone: 502-231-1144
  • Fax: 502-231-1508
Mailing address:
  • Phone: 502-231-1144
  • Fax: 502-231-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number1065462
License Number StateKY

VIII. Authorized Official

Name: LISA PARIS
Title or Position: BILLING
Credential:
Phone: 502-231-1144