Provider Demographics
NPI:1174699359
Name:PREMIUM PEDIATRICS PLLC
Entity type:Organization
Organization Name:PREMIUM PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BODEANU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-789-4788
Mailing Address - Street 1:307 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2003
Mailing Address - Country:US
Mailing Address - Phone:270-789-4788
Mailing Address - Fax:270-572-4227
Practice Address - Street 1:307 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2003
Practice Address - Country:US
Practice Address - Phone:270-789-4788
Practice Address - Fax:270-572-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64128457Medicaid
KY50013851OtherPASSPORT
KY64128457Medicaid