Basic Information
| Provider Information | |||||||||
| NPI: | 1720092240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OWENSBORO PEDIATRICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 E PARRISH AVE | ||||||||
| Address2: | BLDG B SUITE 101 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706833232 | ||||||||
| FaxNumber: | 2708521600 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E PARRISH AVE | ||||||||
| Address2: | BLDG B SUITE 101 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706833232 | ||||||||
| FaxNumber: | 2708521600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
| AuthorizedOfficialMiddleName: | COLLIER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2706833232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1172074 | 05 | KY | MEDICAID | 2003226760A | 05 | IN | MEDICAID | 65939241 | 05 | KY | MEDICAID |