Provider Demographics
NPI:1295461119
Name:RED MAPLE PEDIATRICS LLC
Entity Type:Organization
Organization Name:RED MAPLE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY-FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-438-6622
Mailing Address - Street 1:1621 NASHVILLE ST STE 106
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-8871
Mailing Address - Country:US
Mailing Address - Phone:270-946-1372
Mailing Address - Fax:270-216-6185
Practice Address - Street 1:1621 NASHVILLE ST STE 106
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-8871
Practice Address - Country:US
Practice Address - Phone:270-946-1372
Practice Address - Fax:270-216-6185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-25
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty