Provider Demographics
NPI:1063686509
Name:LEBANON PEDIATRICS LLC
Entity Type:Organization
Organization Name:LEBANON PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-692-5811
Mailing Address - Street 1:311 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1427
Mailing Address - Country:US
Mailing Address - Phone:270-692-5811
Mailing Address - Fax:270-692-3863
Practice Address - Street 1:311 W HIGH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1427
Practice Address - Country:US
Practice Address - Phone:270-692-5811
Practice Address - Fax:270-692-3863
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEBANON PEDIATRICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78905148Medicaid