=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194774760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TYSON, SCHWAB, SHORT & WEISS PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2006
-----------------------------------------------------
Last Update Date | 03/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 ABRAHAM FLEXNER WAY
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-1818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-587-4231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 S 1ST ST SUITE 501
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-5404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-583-2731
-----------------------------------------------------
Fax | 502-583-2733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/RADIOLOGIST
-----------------------------------------------------
Name | DEAN LESLIE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 502-583-2731
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------