Provider Demographics
NPI:1912066085
Name:GATEWAY INTERNAL MEDICINE AND PEDIATRIC ASSOCIATES PLLC
Entity type:Organization
Organization Name:GATEWAY INTERNAL MEDICINE AND PEDIATRIC ASSOCIATES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RAPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-498-7715
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-0689
Mailing Address - Country:US
Mailing Address - Phone:859-498-7716
Mailing Address - Fax:859-497-0044
Practice Address - Street 1:103 COMMONWEALTH DRIVE
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9317
Practice Address - Country:US
Practice Address - Phone:859-498-7716
Practice Address - Fax:859-497-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65934036Medicaid
KY6626Medicare ID - Type UnspecifiedMEDICARE GROUP