Healthcare Provider Details

I. General information

NPI: 1174773188
Provider Name (Legal Business Name): PEDIATRIC PARTNERS OF WESTERN KY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 TRIPLETT ST STE 1000
OWENSBORO KY
42303-3104
US

IV. Provider business mailing address

1102 TRIPLETT ST STE 1000
OWENSBORO KY
42303-3104
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-8828
  • Fax: 270-926-0760
Mailing address:
  • Phone: 270-926-8828
  • Fax: 270-926-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA787
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3007096
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number40582
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number42304
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number21411
License Number StateKY

VIII. Authorized Official

Name: DR. JOHN T HOUSTON
Title or Position: OWNER
Credential: MD
Phone: 270-926-8828