Provider Demographics
NPI:1629200076
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 1:73 KINGSWOOD DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9604
Practice Address - Country:US
Practice Address - Phone:270-789-1112
Practice Address - Fax:270-789-3157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65908238Medicaid
KY65908238Medicaid