Provider Demographics
NPI:1275710907
Name:PEDIATRIC HEMATOLOGY/ONCOLOGY SPECIALISTS
Entity Type:Organization
Organization Name:PEDIATRIC HEMATOLOGY/ONCOLOGY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BERTOLONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:502-629-7750
Mailing Address - Street 1:601 S FLOYD ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1835
Mailing Address - Country:US
Mailing Address - Phone:502-629-7750
Mailing Address - Fax:502-629-7784
Practice Address - Street 1:601 S FLOYD ST
Practice Address - Street 2:SUITE 403
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1835
Practice Address - Country:US
Practice Address - Phone:502-629-7750
Practice Address - Fax:502-629-7784
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC HEMATOLOGY/ONCOLOGY SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78905171Medicaid