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General NPI Number Information
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NPI Number | 1629502604
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Entity Type | Individual
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Provider Name | ETHAN SHORT MD
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Gender | Male
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Dates
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Enumeration Date | 04/17/2017
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Last Update Date | 08/22/2023
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Provider Practice Location Address
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Address Line | 228 DELMONT AVE
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City | LOUISVILLE
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State | KY
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Zip | 40206-1025
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Country | US
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Telephone | 502-619-0636
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Fax |
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Provider Business Mailing Address
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Address Line | 228 DELMONT AVE
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City | LOUISVILLE
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State | KY
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Zip | 40206-1025
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Country | US
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Telephone | 502-619-0636
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 01091358A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | R4865
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 54489
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License Number State | KY
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Taxonomy #4
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 54489
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License Number State | KY
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