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General NPI Number Information
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NPI Number | 1164455952
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Entity Type | Organization
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Legal Business Name | PEDIATRIC GASTROENTEROLOGY PSC
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 05/19/2022
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Provider Practice Location Address
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Address Line | 233 E GRAY ST SUITE 513
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City | LOUISVILLE
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State | KY
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Zip | 40202-2026
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Country | US
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Telephone | 502-629-5796
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Fax | 502-629-5799
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Provider Business Mailing Address
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Address Line | 233 E GRAY ST SUITE 513
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City | LOUISVILLE
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State | KY
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Zip | 40202-2026
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Country | US
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Telephone | 502-629-5796
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Fax | 502-629-5799
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Authorized Official
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Title or Position | PRESIDENT
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Name | THGMAS C STEPHEN
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Credential | M.D
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Telephone | 502-629-5796
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0424168
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License Number State | KY
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