Healthcare Provider Details

I. General information

NPI: 1386070019
Provider Name (Legal Business Name): SUSAN RAGHAVAN, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 PARK PLAZA AVE UNIT 202
LOUISVILLE KY
40241-2290
US

IV. Provider business mailing address

9720 PARK PLAZA AVE UNIT 202
LOUISVILLE KY
40241-2290
US

V. Phone/Fax

Practice location:
  • Phone: 502-327-9703
  • Fax: 502-327-9798
Mailing address:
  • Phone: 502-327-9703
  • Fax: 502-327-9798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number34555
License Number StateKY

VIII. Authorized Official

Name: SUSIE MINSTERKETTER
Title or Position: BILLING DEPT
Credential:
Phone: 502-327-9703