Provider Demographics
NPI:1336298652
Name:PROSPECT PEDIATRICS, PSC
Entity Type:Organization
Organization Name:PROSPECT PEDIATRICS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-228-1312
Mailing Address - Street 1:9217 US HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8858
Mailing Address - Country:US
Mailing Address - Phone:502-228-1312
Mailing Address - Fax:502-753-2998
Practice Address - Street 1:9217 US HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8858
Practice Address - Country:US
Practice Address - Phone:502-228-1312
Practice Address - Fax:502-753-2998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
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
KY65914376000Medicaid