Provider Demographics
NPI:1053605063
Name:PEDIATRIC SPECIALTY CLINIC, LLC.
Entity type:Organization
Organization Name:PEDIATRIC SPECIALTY CLINIC, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-219-2828
Mailing Address - Street 1:1031 WELLINGTON WAY
Mailing Address - Street 2:SUITE 245
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1258
Mailing Address - Country:US
Mailing Address - Phone:859-278-8772
Mailing Address - Fax:859-303-8852
Practice Address - Street 1:2647 REGENCY RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2959
Practice Address - Country:US
Practice Address - Phone:859-276-1088
Practice Address - Fax:859-276-1096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty