Provider Demographics
NPI:1972827707
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:J
Authorized Official - Last Name:BERTOLONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:502-629-7751
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:502-629-7751
Mailing Address - Fax:500-629-5780
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:502-629-7751
Practice Address - Fax:500-629-5780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1505103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100096690Medicaid