Provider Demographics
NPI:1609960830
Name:CORBIN PEDIATRIC ASSOCIATES PSC
Entity Type:Organization
Organization Name:CORBIN PEDIATRIC ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-528-9700
Mailing Address - Street 1:60 BRYAN BOULEVARD
Mailing Address - Street 2:STE 200
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701
Mailing Address - Country:US
Mailing Address - Phone:606-528-9700
Mailing Address - Fax:606-528-8423
Practice Address - Street 1:60 BRYAN BOULEVARD
Practice Address - Street 2:STE 200
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701
Practice Address - Country:US
Practice Address - Phone:606-528-9700
Practice Address - Fax:606-528-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163W00000X, 208000000X, 363LP0200X
KY900173261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100159920Medicaid
KY7100159920Medicaid
KY183929Medicare Oscar/Certification