Provider Demographics
NPI:1033208525
Name:UNIVERSITY PEDIATRIC SURGERY ASSOCIATES, PSC
Entity Type:Organization
Organization Name:UNIVERSITY PEDIATRIC SURGERY ASSOCIATES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:SACRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-583-7337
Mailing Address - Street 1:234 E GRAY ST STE 766
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1901
Mailing Address - Country:US
Mailing Address - Phone:502-583-7337
Mailing Address - Fax:502-584-5437
Practice Address - Street 1:234 E GRAY ST STE 766
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1901
Practice Address - Country:US
Practice Address - Phone:502-583-7337
Practice Address - Fax:502-584-5437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========OtherFEDERAL TAX ID