Healthcare Provider Details

I. General information

NPI: 1336298652
Provider Name (Legal Business Name): PROSPECT PEDIATRICS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9217 US HIGHWAY 42
PROSPECT KY
40059-8858
US

IV. Provider business mailing address

9217 US HIGHWAY 42
PROSPECT KY
40059-8858
US

V. Phone/Fax

Practice location:
  • Phone: 502-228-1312
  • Fax: 502-753-2998
Mailing address:
  • Phone: 502-228-1312
  • Fax: 502-753-2998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TERENCE P MCKENNA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 502-228-1312