Provider Demographics
NPI:1710138367
Name:PEDIATRIC PARTNERS OF WESTERN KY
Entity Type:Organization
Organization Name:PEDIATRIC PARTNERS OF WESTERN KY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-926-8828
Mailing Address - Street 1:2707 BRECKENRIDGE ST
Mailing Address - Street 2:STE. 2
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1385
Mailing Address - Country:US
Mailing Address - Phone:270-926-8828
Mailing Address - Fax:270-929-0760
Practice Address - Street 1:2707 BRECKENRIDGE ST
Practice Address - Street 2:STE. 2
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1385
Practice Address - Country:US
Practice Address - Phone:270-926-8828
Practice Address - Fax:270-929-0760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003752Medicaid
KY95003752Medicaid