Healthcare Provider Details

I. General information

NPI: 1891828604
Provider Name (Legal Business Name): PEDIATRIC HEALTH GROUP PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 HOSPITAL DRIVE
MADISONVILLE KY
42431-1652
US

IV. Provider business mailing address

550 HOSPITAL DRIVE
MADISONVILLE KY
42431-1652
US

V. Phone/Fax

Practice location:
  • Phone: 270-824-9898
  • Fax: 270-824-9185
Mailing address:
  • Phone: 270-824-9898
  • Fax: 270-824-9185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. RENNAN MALAZARTE QUIJANO
Title or Position: PRESIDENT
Credential: MD
Phone: 270-824-9898