Provider Demographics
NPI:1013954510
Name:PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES
Other - Org Name:RED RIVER HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATING MANAGER
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:606-432-0174
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 1:321C E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380-2325
Practice Address - Country:US
Practice Address - Phone:606-663-9797
Practice Address - Fax:606-663-9470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY900183208000000X, 261QR1300X
KYPA1161363A00000X
KY3006123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35001783Medicaid
183934Medicare Oscar/Certification
KY9525Medicare PIN