Provider Demographics
NPI:1376865972
Name:PEARL GERIATRICS AND PALLIATIVE MEDICINE, PSC
Entity Type:Organization
Organization Name:PEARL GERIATRICS AND PALLIATIVE MEDICINE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAWARU
Authorized Official - Middle Name:JUDE
Authorized Official - Last Name:OMORUYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-456-0494
Mailing Address - Street 1:PO BOX 37188
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40233-7188
Mailing Address - Country:US
Mailing Address - Phone:502-456-0494
Mailing Address - Fax:502-456-0496
Practice Address - Street 1:2202 BUECHEL AVE STE 105
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2672
Practice Address - Country:US
Practice Address - Phone:502-456-0494
Practice Address - Fax:504-456-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QG0300X, 207RG0300X
KY39870207R00000X
KY3006777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100159350Medicaid
KY7100134680Medicaid