Provider Demographics
NPI:1225198294
Name:PEDIATRIC AND NEONATAL PRACTICE
Entity Type:Organization
Organization Name:PEDIATRIC AND NEONATAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-647-5468
Mailing Address - Street 1:720 HOSPITAL DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1685
Mailing Address - Country:US
Mailing Address - Phone:502-647-5468
Mailing Address - Fax:502-647-7134
Practice Address - Street 1:720 HOSPITAL DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1685
Practice Address - Country:US
Practice Address - Phone:502-647-5468
Practice Address - Fax:502-647-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29789 AND 295962080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYF47237Medicare UPIN
KYG04319Medicare UPIN