Provider Demographics
NPI:1720894140
Name:PEARL MEDICAL PRACTICE PLLC
Entity type:Organization
Organization Name:PEARL MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAWARU
Authorized Official - Middle Name:
Authorized Official - Last Name:OMORUYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-456-0494
Mailing Address - Street 1:2202 BUECHEL AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2672
Mailing Address - Country:US
Mailing Address - Phone:502-456-0494
Mailing Address - Fax:
Practice Address - Street 1:2615 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-5203
Practice Address - Country:US
Practice Address - Phone:502-338-2964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEARL MEDICAL PRACTICE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health