Provider Demographics
NPI:1871632844
Name:PEDIATRIC HEMATOLOGY-ONCOLOGY SPECIALISTS, PSC
Entity Type:Organization
Organization Name:PEDIATRIC HEMATOLOGY-ONCOLOGY SPECIALISTS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BERTOLONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:502-629-7750
Mailing Address - Street 1:601 S FLOYD ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 S FLOYD ST
Practice Address - Street 2:SUITE 403
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1835
Practice Address - Country:US
Practice Address - Phone:502-629-7750
Practice Address - Fax:502-629-5780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65906513Medicaid