Provider Demographics
NPI:1336209865
Name:PEDIATRIC PARTNERS OF NORTHERN KENTUCKY
Entity Type:Organization
Organization Name:PEDIATRIC PARTNERS OF NORTHERN KENTUCKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPRAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-331-4005
Mailing Address - Street 1:1945 HIGHLAND PIKE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FT WRIGHT
Mailing Address - State:KY
Mailing Address - Zip Code:41017-8127
Mailing Address - Country:US
Mailing Address - Phone:859-331-4005
Mailing Address - Fax:
Practice Address - Street 1:1945 HIGHLAND PIKE
Practice Address - Street 2:SUITE 1
Practice Address - City:FT WRIGHT
Practice Address - State:KY
Practice Address - Zip Code:41017-8127
Practice Address - Country:US
Practice Address - Phone:859-331-4005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65943961Medicaid