=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336358399
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN GREGORY O'HERN OTRL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 833 FORREST ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40217-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-558-3345
-----------------------------------------------------
Fax | 502-635-9005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 833 FORREST ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40217-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-558-3345
-----------------------------------------------------
Fax | 502-635-9005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | RO313
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------