Healthcare Provider Details

I. General information

NPI: 1053874776
Provider Name (Legal Business Name): JACKSON GEORGE UNTERINER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AUDUBON PLAZA DR
LOUISVILLE KY
40217-1318
US

IV. Provider business mailing address

9152 TAYLORSVILLE RD # 276
LOUISVILLE KY
40299-1752
US

V. Phone/Fax

Practice location:
  • Phone: 502-447-8786
  • Fax: 502-447-8786
Mailing address:
  • Phone: 502-447-8786
  • Fax: 502-447-8623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number60448
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2020011736
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number60448
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: