Provider Demographics
NPI:1235795352
Name:PROFESSIONAL PARK DIAGNOSTICS PLLC
Entity Type:Organization
Organization Name:PROFESSIONAL PARK DIAGNOSTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:GIPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-685-1066
Mailing Address - Street 1:3346 PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-685-1066
Mailing Address - Fax:270-713-0227
Practice Address - Street 1:3346 PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-685-1066
Practice Address - Fax:270-713-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100633920Medicaid