Healthcare Provider Details

I. General information

NPI: 1376547711
Provider Name (Legal Business Name): IRWIN RANDELL COHEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4006 DUTCHMANS LN SUITE 100
LOUISVILLE KY
40207-4704
US

IV. Provider business mailing address

4307 GLENARM RD
CRESTWOOD KY
40014-9586
US

V. Phone/Fax

Practice location:
  • Phone: 502-873-7517
  • Fax:
Mailing address:
  • Phone: 502-241-2892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number29908
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2011000734
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number29908
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: