MEDICARE: PEDIATRIC ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	900183	KY
2	363LF0000X	Family Nurse Practitioner	3006123	KY
3	363A00000X	Physician Assistant	PA1161	KY
4	261QR1300X	Rural Health Clinic/Center	900183	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013954510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC ASSOCIATES

Provider Business Mailing Address
First Line	:	PO BOX 2748
Second Line	:
City	:	PIKEVILLE
State	:	KY
Zip	:	41502-2748
Country	:	US
Telephone Number	:	606-432-3221
Fax Number	:	606-437-0438

Provider Business Practice Location Address
First Line	:	321C E COLLEGE AVE
Second Line	:
City	:	STANTON
State	:	KY
Zip	:	40380-2325
Country	:	US
Telephone Number	:	606-663-9797
Fax Number	:	606-663-9470

Authorized Official
Title or Position	:	OPERATING MANAGER
Name	:	DJIEN HWAT SO
Credential	:
Telephone Number	:	606-432-0174

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	03/21/2017

Similar Medicare Providers

1578716213 — MRS. SARAH L MURPHY PA-C
Practice Location Address:

321C E COLLEGE AVE
STANTON, KY
40380-2325

Practice Phone: 606-663-9797
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1659917524 — MARIE DAWN BAKER APRN
Practice Location Address:

321C E COLLEGE AVE
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40380-2325

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1629708052 — HALEY BERRYMAN BLOOM APRN
Practice Location Address:

321C E COLLEGE AVE
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40380-2325

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1780683524 — COUNTY OF POWELL
Practice Location Address:

56 ATKINSON ST
STANTON, KY
40380-2514

Practice Phone: 606-663-0376
Practice Fax: 304-521-1576

1093708554 — MS. GENEIVIVE BREWER LCSW
Practice Location Address:

638 E COLLEGE AVE STE B
STANTON, KY
40380-2363

Practice Phone: 606-318-3500
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1003897273 — DR. GARY M THOMPSON DMD
Practice Location Address:

131 N MAIN ST
STANTON, KY
40380-2174

Practice Phone: 606-663-2133
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Directions to “PEDIATRIC ASSOCIATES ” Practice Location

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