Provider Demographics
NPI:1891828604
Name:PEDIATRIC HEALTH GROUP PSC
Entity Type:Organization
Organization Name:PEDIATRIC HEALTH GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENNAN
Authorized Official - Middle Name:MALAZARTE
Authorized Official - Last Name:QUIJANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-824-9898
Mailing Address - Street 1:550 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1652
Mailing Address - Country:US
Mailing Address - Phone:270-824-9898
Mailing Address - Fax:270-824-9185
Practice Address - Street 1:550 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1652
Practice Address - Country:US
Practice Address - Phone:270-824-9898
Practice Address - Fax:270-824-9185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty