Provider Demographics
NPI:1063650471
Name:MT. STERLING PEDIATRICS
Entity Type:Organization
Organization Name:MT. STERLING PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:B
Authorized Official - Last Name:FOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-498-5243
Mailing Address - Street 1:401 COMMERCE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-7815
Mailing Address - Country:US
Mailing Address - Phone:859-498-5243
Mailing Address - Fax:859-498-5396
Practice Address - Street 1:401 COMMERCE CIRCLE
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-7815
Practice Address - Country:US
Practice Address - Phone:859-498-5243
Practice Address - Fax:859-498-5396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363A00000X
KY39940208000000X
KY5332P363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100198270Medicaid