Healthcare Provider Details

I. General information

NPI: 1205079134
Provider Name (Legal Business Name): MAYFIELD PEDIATRIC CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 S 6TH ST
MAYFIELD KY
42066
US

IV. Provider business mailing address

417 S. 6TH ST.
MAYFIELD KY
42066
US

V. Phone/Fax

Practice location:
  • Phone: 270-247-1104
  • Fax: 270-247-1107
Mailing address:
  • Phone: 270-247-1104
  • Fax: 270-247-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41115
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41115
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number41115
License Number StateKY

VIII. Authorized Official

Name: ABID HUSSAIN
Title or Position: OWNER
Credential: M.D.
Phone: 270-247-1104