Provider Demographics
NPI:1205939568
Name:PEDIATRIC ANAESTHESIA ASSOCIATES, PSC
Entity type:Organization
Organization Name:PEDIATRIC ANAESTHESIA ASSOCIATES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-451-9949
Mailing Address - Street 1:DEPARTMENT 5090
Mailing Address - Street 2:PO BOX 740041
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-7441
Mailing Address - Country:US
Mailing Address - Phone:502-451-9949
Mailing Address - Fax:502-451-4553
Practice Address - Street 1:231 E CHESTNUT ST
Practice Address - Street 2:KOSAIR CHILDRENS HOSPITAL
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1821
Practice Address - Country:US
Practice Address - Phone:502-451-9949
Practice Address - Fax:502-451-4553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207LP3000X, 207L00000X
KY367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65914699Medicaid
KY2156Medicare PIN