Provider Demographics
NPI:1104103985
Name:DANVILLE PEDIATRICS AND PRIMARY CARE, PLLC
Entity type:Organization
Organization Name:DANVILLE PEDIATRICS AND PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-236-1080
Mailing Address - Street 1:303 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2091
Mailing Address - Country:US
Mailing Address - Phone:859-236-1080
Mailing Address - Fax:859-236-1862
Practice Address - Street 1:1180 GLENSBORO RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342-9034
Practice Address - Country:US
Practice Address - Phone:859-236-1080
Practice Address - Fax:859-236-1862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100000530Medicaid