Provider Demographics
NPI:1669415493
Name:MERCER PEDIATRICS PSC
Entity type:Organization
Organization Name:MERCER PEDIATRICS PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-734-5123
Mailing Address - Street 1:PO BOX 364
Mailing Address - Street 2:466 LINDEN AVENUE
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-0364
Mailing Address - Country:US
Mailing Address - Phone:859-734-5123
Mailing Address - Fax:859-734-0664
Practice Address - Street 1:466 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-1841
Practice Address - Country:US
Practice Address - Phone:859-734-5123
Practice Address - Fax:859-734-0664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25108208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65929507Medicaid
KY610510934Medicaid