Healthcare Provider Details

I. General information

NPI: 1518062793
Provider Name (Legal Business Name): GEORGE WAYNE MADER RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AUDUBON PLAZA DR
LOUISVILLE KY
40217-1318
US

IV. Provider business mailing address

14612 WOODSTREAM PL
LOUISVILLE KY
40245-5164
US

V. Phone/Fax

Practice location:
  • Phone: 502-636-7311
  • Fax:
Mailing address:
  • Phone: 502-244-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number08 KY 1003
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: