Basic Information
| Provider Information | |||||||||
| NPI: | 1386813319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PADGETT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12647 OLIVE BLVD | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416393 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 289 IRELAND AVE | ||||||||
| Address2: | PEDIATRIC CLINIC | ||||||||
| City: | FORT KNOX | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401215111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026249333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2008 | ||||||||
| LastUpdateDate: | 02/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 13933 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 64139330 | 05 | KY | MEDICAID |