Healthcare Provider Details

I. General information

NPI: 1336379544
Provider Name (Legal Business Name): ROCKCASTLE PEDIATRICS & ADOLESCENTS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 02/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 NEWCOMB AVE
MOUNT VERNON KY
40456-2728
US

IV. Provider business mailing address

PO BOX 1020
MOUNT VERNON KY
40456-1020
US

V. Phone/Fax

Practice location:
  • Phone: 606-256-4148
  • Fax: 606-256-7785
Mailing address:
  • Phone: 606-256-4148
  • Fax: 606-256-7785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateKY

VIII. Authorized Official

Name: CALLIE SHAFFER
Title or Position: OWNER
Credential: M.D.
Phone: 606-256-4148