Provider Demographics
NPI:1114261203
Name:PEARL MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:PEARL MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OSAWARU
Authorized Official - Middle Name:
Authorized Official - Last Name:OMORUYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-456-0494
Mailing Address - Street 1:4200 GARDINER VIEW AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1877
Mailing Address - Country:US
Mailing Address - Phone:502-456-0494
Mailing Address - Fax:502-456-0496
Practice Address - Street 1:4200 GARDINER VIEW AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1877
Practice Address - Country:US
Practice Address - Phone:502-456-0494
Practice Address - Fax:502-456-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100267920Medicaid
KY7100259660Medicaid
KY7100267920Medicaid