Healthcare Provider Details

I. General information

NPI: 1104821735
Provider Name (Legal Business Name): MICHAEL V. GREENWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 KRESGE WAY STE 207
LOUISVILLE KY
40207-4637
US

IV. Provider business mailing address

PO BOX 950296
LOUISVILLE KY
40295-0296
US

V. Phone/Fax

Practice location:
  • Phone: 502-893-0220
  • Fax: 502-893-0563
Mailing address:
  • Phone: 502-893-0220
  • Fax: 502-893-0563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number207RG0100X
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number24686
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: