Healthcare Provider Details

I. General information

NPI: 1306882170
Provider Name (Legal Business Name): MARY T SELF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 DUTCHMANS PKWY STE 345
LOUISVILLE KY
40205-3370
US

IV. Provider business mailing address

100 E LIBERTY ST SUITE 800
LOUISVILLE KY
40202-1434
US

V. Phone/Fax

Practice location:
  • Phone: 502-587-6010
  • Fax: 502-587-1314
Mailing address:
  • Phone: 502-587-6010
  • Fax: 502-587-1314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number24710
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: