Provider Demographics
NPI:1669523460
Name:PAINTSVILLE PEDIATRIC ASSOCIATES
Entity type:Organization
Organization Name:PAINTSVILLE PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YASSIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHATTAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-789-5541
Mailing Address - Street 1:822 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1384
Mailing Address - Country:US
Mailing Address - Phone:606-789-5541
Mailing Address - Fax:606-789-9445
Practice Address - Street 1:822 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1384
Practice Address - Country:US
Practice Address - Phone:606-789-5541
Practice Address - Fax:606-789-9445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31001019Medicaid
KY000000203757OtherANTHEM BLUE C BLUE S
KY31001019Medicaid