Provider Demographics
NPI:1902031602
Name:SOMERSET PEDIATRIC SPECIALISTS PLLC
Entity Type:Organization
Organization Name:SOMERSET PEDIATRIC SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-678-8155
Mailing Address - Street 1:350 LANGDON ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2786
Mailing Address - Country:US
Mailing Address - Phone:606-678-8155
Mailing Address - Fax:
Practice Address - Street 1:350 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2786
Practice Address - Country:US
Practice Address - Phone:606-678-8155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100087290 - MDMedicaid
KY7100087330 - NPMedicaid