Basic Information
| Provider Information | |||||||||
| NPI: | 1508992512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY CHILDREN'S CONSCIOUS SEDATION SPECIALISTS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY CHILDREN'S SEDATION SERVICE, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 2469 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402012469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028528500 | ||||||||
| FaxNumber: | 5028528556 | ||||||||
| Practice Location | |||||||||
| Address1: | 231 E CHESTNUT STREET | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028528500 | ||||||||
| FaxNumber: | 5028528556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | RABALAIS | ||||||||
| AuthorizedOfficialFirstName: | GERARD | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5028528500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 2080P0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 207LP3000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 65940702 | 05 | KY | MEDICAID | 78904166 | 05 | KY | MEDICAID | 200454140A | 05 | IN | MEDICAID |