Provider Demographics
NPI:1255463949
Name:VANDERBILT INTEGRATED PROVIDERS
Entity Type:Organization
Organization Name:VANDERBILT INTEGRATED PROVIDERS
Other - Org Name:PEDIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-936-5187
Mailing Address - Street 1:1717 HIGH STREET
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240
Mailing Address - Country:US
Mailing Address - Phone:270-885-8445
Mailing Address - Fax:270-886-9106
Practice Address - Street 1:1717 HIGH STREET
Practice Address - Street 2:SUITE 3A
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240
Practice Address - Country:US
Practice Address - Phone:270-885-8445
Practice Address - Fax:270-886-9106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VANDERBILT INTEGRATED PROVIDERS D.B.A PEDIATRIC ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LP0200X
KY3002428363LP0200X
KY3004549363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78900800Medicaid