Basic Information
| Provider Information | |||||||||
| NPI: | 1114261203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEARL MEDICAL PRACTICE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 GARDINER VIEW AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402131877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024560494 | ||||||||
| FaxNumber: | 5024560496 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 GARDINER VIEW AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402131877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024560494 | ||||||||
| FaxNumber: | 5024560496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | OMORUYI | ||||||||
| AuthorizedOfficialFirstName: | OSAWARU | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5024560494 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 7100267920 | 05 | KY | MEDICAID | 7100259660 | 05 | KY | MEDICAID |