Healthcare Provider Details

I. General information

NPI: 1992763494
Provider Name (Legal Business Name): MICHAEL WAYNE MCQUILLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 KRESGE WAY SUITE 100
LOUISVILLE KY
40207-4640
US

IV. Provider business mailing address

2700 STANLEY GAULT PKWY SUITE 129
LOUISVILLE KY
40223-5132
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-6579
  • Fax: 502-897-2725
Mailing address:
  • Phone: 502-253-4917
  • Fax: 502-489-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number39813
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number39813
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number39813
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: