Basic Information
| Provider Information | |||||||||
| NPI: | 1487953311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PEDIATRIC GASTROENTEROLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2469 | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402012469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028528500 | ||||||||
| FaxNumber: | 5028528556 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 2ND ST | ||||||||
| Address2: | STE 102 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028527670 | ||||||||
| FaxNumber: | 5028527743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2011 | ||||||||
| LastUpdateDate: | 04/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | RABALAIS | ||||||||
| AuthorizedOfficialFirstName: | GERARD | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 5028528600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0206X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 200945670 | 05 | IN | MEDICAID | 7100063520 | 05 | KY | MEDICAID |