Provider Demographics
NPI:1295092963
Name:UNIVERSITY PEDIATRICS FOUNDATION, INC.
Entity type:Organization
Organization Name:UNIVERSITY PEDIATRICS FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:RABALAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-852-8600
Mailing Address - Street 1:PO BOX 2469
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-2469
Mailing Address - Country:US
Mailing Address - Phone:502-852-8500
Mailing Address - Fax:502-852-8556
Practice Address - Street 1:215 CENTRAL AVE
Practice Address - Street 2:STE. 205
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1449
Practice Address - Country:US
Practice Address - Phone:502-629-3320
Practice Address - Fax:502-852-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/ImmunologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65908238Medicaid
IN100005790Medicaid
KY65908238Medicaid