=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215005418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PULMONARY & CRITICAL CARE CONSULTANTS OF LOUISVILLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 11/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1455 CEDAR ST
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47129-7700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-552-2955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1455 CEDAR ST
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47129-7700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-689-1835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LAWRENCE ROUBEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 502-552-2955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 26070
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------