Provider Demographics
NPI:1649577362
Name:UNIVERSITY PEDIATRIC PULMONARY, LLC
Entity Type:Organization
Organization Name:UNIVERSITY PEDIATRIC PULMONARY, LLC
Other - Org Name:
Other - Org Type:
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 1:9700 PARK PLAZA AVE
Practice Address - Street 2:STE 110
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2286
Practice Address - Country:US
Practice Address - Phone:502-629-8830
Practice Address - Fax:502-629-7540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100115770Medicaid
KY710018920Medicaid
IN200998250Medicaid
KY01457Medicare PIN