Basic Information
| Provider Information | |||||||||
| NPI: | 1700936754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLASGOW PEDIATRIC ASSOCIATES PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706519696 | ||||||||
| FaxNumber: | 2706510385 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706519696 | ||||||||
| FaxNumber: | 2706510385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 10/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | DENNISON | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2706519696 | ||||||||
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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 | 207Q00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 65935595 | 05 | KY | MEDICAID |