Provider Demographics
NPI:1336379544
Name:ROCKCASTLE PEDIATRICS & ADOLESCENTS PSC
Entity Type:Organization
Organization Name:ROCKCASTLE PEDIATRICS & ADOLESCENTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-256-4148
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-1020
Mailing Address - Country:US
Mailing Address - Phone:606-256-4148
Mailing Address - Fax:606-256-7785
Practice Address - Street 1:140 NEWCOMB AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-2728
Practice Address - Country:US
Practice Address - Phone:606-256-4148
Practice Address - Fax:606-256-7785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2013-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208000000X, 261QR1300X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100081050Medicaid
KY7100081050Medicaid
KY1208Medicare PIN