Provider Demographics
NPI:1023376456
Name:PJ PERSSON, PSC
Entity Type:Organization
Organization Name:PJ PERSSON, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PERJOHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-940-0146
Mailing Address - Street 1:602 GOLFVIEW TER
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1947
Mailing Address - Country:US
Mailing Address - Phone:270-692-9559
Mailing Address - Fax:270-692-9236
Practice Address - Street 1:312 W HIGH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1428
Practice Address - Country:US
Practice Address - Phone:270-692-9559
Practice Address - Fax:270-692-9236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43219208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty