Provider Demographics
NPI:1740310168
Name:MOUNTAIN PEDIATRICS
Entity type:Organization
Organization Name:MOUNTAIN PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERRARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-638-4888
Mailing Address - Street 1:TRM PLAZA
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230
Mailing Address - Country:US
Mailing Address - Phone:606-638-4888
Mailing Address - Fax:606-638-9003
Practice Address - Street 1:TRM PLAZA
Practice Address - Street 2:SUITE 203
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230
Practice Address - Country:US
Practice Address - Phone:606-638-4888
Practice Address - Fax:606-638-9003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64324544Medicaid