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General NPI Number Information
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NPI Number | 1033366091
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Entity Type | Organization
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Legal Business Name | UNIVERSITY PEDIATRIC GASTROENTEROLOGY, LLC
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Dates
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Enumeration Date | 08/21/2008
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Last Update Date | 08/20/2009
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Provider Practice Location Address
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Address Line | 210 E GRAY STREET STE 802
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City | LOUISVILLE
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State | KY
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Zip | 40202-3904
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Country | US
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Telephone | 502-852-7670
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2469
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City | LOUISVILLE
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State | KY
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Zip | 40201-2469
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Country | US
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Telephone | 502-852-8500
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Fax | 502-852-8556
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Authorized Official
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Title or Position | PRESIDENT
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Name | GERARD P. RABALAIS
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Credential | MD
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Telephone | 502-852-8600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0206X
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Taxonomy Name | Pediatric Gastroenterology Physician
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License Number |
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License Number State |
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