Provider Demographics
NPI:1851348338
Name:PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES
Other - Org Name:PEDIATRIC ASSOCIATES OF PIKEVILLE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DJIEN
Authorized Official - Middle Name:HWAT
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-432-3221
Mailing Address - Street 1:PO BOX 2748
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2748
Mailing Address - Country:US
Mailing Address - Phone:606-432-3221
Mailing Address - Fax:606-437-0438
Practice Address - Street 1:156 ISLAND CREEK ROAD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-432-3221
Practice Address - Fax:606-437-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42956208000000X
KY900119261QR1300X
KY3006127363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35001205Medicaid
KY18-3880OtherRURAL HEALTH PALMETTO
KY35001205Medicaid
KY35001783Medicaid