Healthcare Provider Details

I. General information

NPI: 1902287832
Provider Name (Legal Business Name): BODY SHAPE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 SPRINGHURST BLVD
LOUISVILLE KY
40241-6161
US

IV. Provider business mailing address

4211 SPRINGHURST BLVD
LOUISVILLE KY
40241-6161
US

V. Phone/Fax

Practice location:
  • Phone: 502-638-4906
  • Fax:
Mailing address:
  • Phone: 502-638-4906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number3009403
License Number StateKY

VIII. Authorized Official

Name: ELIZABETH BATES
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 502-638-4906