Provider Demographics
NPI:1518235704
Name:UNIVERSITY PEDIATRICS FOUNDATION, INC.
Entity Type:Organization
Organization Name:UNIVERSITY PEDIATRICS FOUNDATION, INC.
Other - Org Name:UNIVERSITY CHILD HEALTH SPECIALISTS, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:RABALAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-852-8600
Mailing Address - Street 1:PO BOX 2469
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-2469
Mailing Address - Country:US
Mailing Address - Phone:502-852-8500
Mailing Address - Fax:502-852-8556
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:STE. 802
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-852-6633
Practice Address - Fax:502-852-7743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65908238Medicaid
KY0789Medicare PIN