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General NPI Number Information
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NPI Number | 1649522616
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Entity Type | Organization
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Legal Business Name | PEDIATRIC CLINIC
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Dates
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Enumeration Date | 10/15/2012
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Last Update Date | 10/15/2012
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Provider Practice Location Address
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Address Line | 3604 CUMBERLAND AVE
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City | MIDDLESBORO
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State | KY
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Zip | 40965-2614
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Country | US
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Telephone | 606-248-8282
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Fax | 606-248-0030
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Provider Business Mailing Address
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Address Line | 3604 WEST CUMBERLAND AVENUE
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City | MIDDLESBORO
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State | KY
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Zip | 40965
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Country | US
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Telephone | 606-248-8282
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Fax | 606-248-0030
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. HOUSHANG KHORRAM
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Credential | MD
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Telephone | 606-248-8282
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 164526
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License Number State | KY
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