Provider Demographics
NPI:1700936754
Name:GLASGOW PEDIATRIC ASSOCIATES PSC
Entity Type:Organization
Organization Name:GLASGOW PEDIATRIC ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:B
Authorized Official - Last Name:DENNISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-651-9696
Mailing Address - Street 1:301 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3487
Mailing Address - Country:US
Mailing Address - Phone:270-651-9696
Mailing Address - Fax:270-651-0385
Practice Address - Street 1:301 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3487
Practice Address - Country:US
Practice Address - Phone:270-651-9696
Practice Address - Fax:270-651-0385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65935595Medicaid