Basic Information
| Provider Information | |||||||||
| NPI: | 1033270434 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC PULMONARY MEDICINE, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 DIXIE HIGHWAY | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024515855 | ||||||||
| FaxNumber: | 5024791409 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 EAST GRAY STREET | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028523772 | ||||||||
| FaxNumber: | 5028524051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EID | ||||||||
| AuthorizedOfficialFirstName: | NEMR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER OF PRACTICE | ||||||||
| AuthorizedOfficialTelephone: | 5028523772 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | 25574 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 1050575 | 01 | KY | PASSPORT GROUP NUMBER | OTHER | 65921991 | 05 | KY | MEDICAID |