Organization
PEDIATRIC GROUP OF PADUCAH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DANA L EVANS (PROVIDER ENROLLMENT SPECIALIST)
(270) 744-9600
Entity
Organization
Contact information
Practice address
2605 KENTUCKY AVE, BLDG 3 SUITE 501, PADUCAH, KY 42003-3800
(270) 443-7534
Mailing address
PO BOX 9150, PADUCAH, KY 42002-9150
(270) 744-9600
(270) 744-8642
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
20596
KY
208000000X
Pediatrics Physician
22172
KY
208000000X
Pediatrics Physician
28040
KY
208000000X
Pediatrics Physician
30516
KY
208000000X
Pediatrics Physician
43274
KY
363LF0000X
Family Nurse Practitioner
3007447
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
65923377
—
KY
Enumeration date
07/01/2006
Last updated
08/05/2013
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