Healthcare Provider Details

I. General information

NPI: 1477795086
Provider Name (Legal Business Name): JACKSON PURCHASE PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 MEDICAL CENTER CIR SUITE 200
MAYFIELD KY
42066-1189
US

IV. Provider business mailing address

1029 MEDICAL CENTER CIR SUITE 200
MAYFIELD KY
42066-1189
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-4545
  • Fax: 270-251-4546
Mailing address:
  • Phone: 270-251-4545
  • Fax: 270-251-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPENDING
License Number StateKY

VIII. Authorized Official

Name: ANNALEE LYNN PAUL
Title or Position: MD/OWNER
Credential: MD
Phone: 270-251-4545