Provider Demographics
NPI:1003875709
Name:PARKWAY PEDIATRICS PSC
Entity Type:Organization
Organization Name:PARKWAY PEDIATRICS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:INDIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODUMANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-864-7337
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741
Mailing Address - Country:US
Mailing Address - Phone:606-864-7337
Mailing Address - Fax:606-878-3257
Practice Address - Street 1:809 MEYERS BAKER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3025
Practice Address - Country:US
Practice Address - Phone:606-864-7337
Practice Address - Fax:606-878-3257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36054208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65942187Medicaid
KY65942187Medicaid
0752301Medicare ID - Type Unspecified