Healthcare Provider Details

I. General information

NPI: 1013313162
Provider Name (Legal Business Name): MT STERLING PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 NEW TOWNE SQUARE
MOREHEAD KY
40351
US

IV. Provider business mailing address

PO BOX 1347
MT STERLING KY
40353-5347
US

V. Phone/Fax

Practice location:
  • Phone: 606-740-0986
  • Fax: 606-780-9096
Mailing address:
  • Phone: 859-498-5243
  • Fax: 859-498-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRANDY B FOUCH
Title or Position: OWNER
Credential: M.D.
Phone: 859-498-5243