Provider Demographics
NPI:1265567572
Name:LOUISVILLE INTERNAL MEDICINE & PEDIATRICS, LLC
Entity type:Organization
Organization Name:LOUISVILLE INTERNAL MEDICINE & PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PALLARES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-454-5252
Mailing Address - Street 1:3101 BRECKENRIDGE LN
Mailing Address - Street 2:#4E
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2742
Mailing Address - Country:US
Mailing Address - Phone:502-454-5252
Mailing Address - Fax:502-454-5353
Practice Address - Street 1:3101 BRECKENRIDGE LN
Practice Address - Street 2:#4E
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2742
Practice Address - Country:US
Practice Address - Phone:502-454-5252
Practice Address - Fax:502-454-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30532208000000X, 207R00000X
KY002051P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYDC4936Medicare PIN
KY9259Medicare PIN