Healthcare Provider Details

I. General information

NPI: 1124151097
Provider Name (Legal Business Name): RADCLIFF PEDIATRICS ,PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W LINCOLN TRAIL BLVD
RADCLIFF KY
40160
US

IV. Provider business mailing address

750 W LINCOLN TRAIL BLVD
RADCLIFF KY
40160
US

V. Phone/Fax

Practice location:
  • Phone: 270-351-1850
  • Fax: 270-351-1855
Mailing address:
  • Phone: 270-351-1850
  • Fax: 270-351-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24932
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. HY K NGUYEN
Title or Position: MD
Credential: MD
Phone: 270-351-1850