Healthcare Provider Details

I. General information

NPI: 1336144401
Provider Name (Legal Business Name): CHRISTOPHER LARS JOHNSRUDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date: 01/30/2022
Reactivation Date: 02/10/2022

III. Provider practice location address

411 E CHESTNUT ST # 5A
LOUISVILLE KY
40202-1713
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6879
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-7450
  • Fax: 502-588-7728
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number37041
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number37041
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: