Provider Demographics
NPI:1518021237
Name:THE CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:THE CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:SAGMIT
Authorized Official - Last Name:BAULA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:270-769-6888
Mailing Address - Street 1:75 WOODSBEND RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9502
Mailing Address - Country:US
Mailing Address - Phone:270-737-4709
Mailing Address - Fax:
Practice Address - Street 1:596 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2949
Practice Address - Country:US
Practice Address - Phone:270-679-6888
Practice Address - Fax:270-769-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363L00000X174400000X
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1110486Medicaid