Provider Demographics
NPI:1669841631
Name:PEARL MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:PEARL MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OSAWARU
Authorized Official - Middle Name:JUDE
Authorized Official - Last Name:OMORUYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-456-0494
Mailing Address - Street 1:PO BOX 35294
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40232-5294
Mailing Address - Country:US
Mailing Address - Phone:502-456-0494
Mailing Address - Fax:502-456-0496
Practice Address - Street 1:2202 BUECHEL AVE STE 105
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2672
Practice Address - Country:US
Practice Address - Phone:502-456-0494
Practice Address - Fax:502-456-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty