Organization
PEDIATRIC GASTROENTEROLOGY PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THGMAS C STEPHEN M.D (PRESIDENT)
(502) 629-5796
Entity
Organization
Contact information
Practice address
233 E GRAY ST, SUITE 513, LOUISVILLE, KY 40202-2026
(502) 629-5796
(502) 629-5799
Mailing address
233 E GRAY ST, SUITE 513, LOUISVILLE, KY 40202-2026
(502) 629-5796
(502) 629-5799
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
0424168
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1049092
PASSPORT GROUP NUMBER
KY
05
—
200140610A
—
IN
05
—
65927816
—
KY
Enumeration date
07/08/2006
Last updated
05/19/2022
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