Healthcare Provider Details

I. General information

NPI: 1912066085
Provider Name (Legal Business Name): GATEWAY INTERNAL MEDICINE AND PEDIATRIC ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 COMMONWEALTH DRIVE
MT STERLING KY
40353-9317
US

IV. Provider business mailing address

PO BOX 689
MT STERLING KY
40353-0689
US

V. Phone/Fax

Practice location:
  • Phone: 859-498-7716
  • Fax: 859-497-0044
Mailing address:
  • Phone: 859-498-7716
  • Fax: 859-497-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. DONNA LYNN RAPER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 859-498-7715