NPIMap

Organization Active NPI

Pediatric Associates

Doing business as Pediatric Associates of Pikeville, LLC

  • Rural Health Clinic/Center
  • Pikeville, KY
National Provider Identifier
1851348338
Registry record updated Mar 27, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
900119 Issued in KY
Legal business name
PEDIATRIC ASSOCIATES
Doing business as
Pediatric Associates of Pikeville, LLC
Practice address
156 Island Creek Road
Pikeville, KY 41501
Phone
(606) 432-3221
Fax
(606) 437-0438
NPI assigned
May 28, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 27, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Djien Hwat So
Title
Administrator
Phone
(606) 432-3221

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X 42956 KY
Rural Health Clinic/Center 261QR1300X 900119 KY Primary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X 3006127 KY

Addresses

Primary practice location

156 Island Creek Road
Pikeville, KY 41501

Mailing address

PO Box 2748
Pikeville, KY 41502-2748
Phone (606) 432-3221

Other identifiers 2

IdentifierTypeStateIssuer
35001205MedicaidKY
18-3880OtherKYRURAL HEALTH PALMETTO

Other names 1

  • Pediatric Associates of Pikeville, LLC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050211000269 KY Part B Supplier - Clinic/Group Practice 9436147048 Receives reassigned benefits from 14 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Hazard, KY; Stanton, KY; Pikeville, KY
O20090306000377 KY Part A Provider - Rural Health Clinic 9436147048 Practice locations: Pikeville, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1851348338. Details of each certification follow.

Rural health clinic certification: CCN 183880

Legal name
PEDIATRIC ASSOCIATES
Doing business as
PEDIATRIC ASSOCIATES OF PIKEVILLE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 8, 2001
Last certification
May 5, 2016
Ownership / control type
1C
Organization structure
LLCProprietary
Enrollment address
156 Island Creek Road
Pikeville, KY 41501-9340

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
18D0982356Pediatric Associates of Pikeville156 Island Creek Road, Pikeville, KY 41501Certificate of waiverJan 22, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Djien So Individual 5% Or Greater Direct Ownership Interest May 8, 2009
W-2 Managing Employee May 8, 2009

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148774400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1553644800000",
    "number": "1851348338",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2748",
            "city": "PIKEVILLE",
            "state": "KY",
            "postal_code": "415022748",
            "telephone_number": "606-432-3221",
            "fax_number": "606-437-0438"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "156 ISLAND CREEK ROAD",
            "city": "PIKEVILLE",
            "state": "KY",
            "postal_code": "41501",
            "telephone_number": "606-432-3221",
            "fax_number": "606-437-0438"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC ASSOCIATES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-28",
        "last_updated": "2019-03-27",
        "status": "A",
        "authorized_official_last_name": "SO",
        "authorized_official_first_name": "DJIEN",
        "authorized_official_middle_name": "HWAT",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "606-432-3221"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "KY",
            "license": "42956",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "KY",
            "license": "900119",
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "KY",
            "license": "3006127",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "35001205",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RURAL HEALTH PALMETTO",
            "identifier": "18-3880",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pediatric Associates of Pikeville, LLC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Pediatric Associates of Pikeville, LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pikeville, KY

Sources for this page

Verify at the official NPI Registry.