Provider Demographics
NPI:1265656136
Name:PEDIATRIC & ADOLESCENT ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC & ADOLESCENT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-977-3044
Mailing Address - Street 1:3050 HARRODSBURG RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2747
Mailing Address - Country:US
Mailing Address - Phone:859-977-3044
Mailing Address - Fax:859-977-0237
Practice Address - Street 1:171 N EAGLE CREEK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1801
Practice Address - Country:US
Practice Address - Phone:859-977-3044
Practice Address - Fax:859-977-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65911612Medicaid
KY65911612Medicaid