Provider Demographics
NPI:1952365215
Name:NORTHERN KENTUCKY PEDIATRIC GROUP PSC
Entity type:Organization
Organization Name:NORTHERN KENTUCKY PEDIATRIC GROUP PSC
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:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-441-7600
Mailing Address - Street 1:1805 ALEXANDRIA PIKE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:KY
Mailing Address - Zip Code:41076
Mailing Address - Country:US
Mailing Address - Phone:859-441-7600
Mailing Address - Fax:859-441-7144
Practice Address - Street 1:1805 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076
Practice Address - Country:US
Practice Address - Phone:859-441-7600
Practice Address - Fax:859-441-7144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65906224Medicaid