Provider Demographics
NPI:1164455952
Name:PEDIATRIC GASTROENTEROLOGY PSC
Entity Type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THGMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:STEPHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-629-5796
Mailing Address - Street 1:233 E GRAY ST
Mailing Address - Street 2:SUITE 513
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2026
Mailing Address - Country:US
Mailing Address - Phone:502-629-5796
Mailing Address - Fax:502-629-5799
Practice Address - Street 1:233 E GRAY ST
Practice Address - Street 2:SUITE 513
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2026
Practice Address - Country:US
Practice Address - Phone:502-629-5796
Practice Address - Fax:502-629-5799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0424168261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1049092OtherPASSPORT GROUP NUMBER
IN200140610AMedicaid
KY65927816Medicaid
KY1049092OtherPASSPORT GROUP NUMBER
KY5513Medicare PIN