Provider Demographics
NPI:1114029212
Name:CRIDER JOHNSON PEDIATRICS PSC
Entity Type:Organization
Organization Name:CRIDER JOHNSON PEDIATRICS PSC
Other - Org Name:JYOTHI METTU MD PSC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-437-1008
Mailing Address - Street 1:387 TOWN MOUNTAIN RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1640
Mailing Address - Country:US
Mailing Address - Phone:606-437-1056
Mailing Address - Fax:606-437-5040
Practice Address - Street 1:387 TOWN MOUNTAIN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1640
Practice Address - Country:US
Practice Address - Phone:606-437-1056
Practice Address - Fax:606-437-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100207560Medicaid