=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912254723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF LOUISVILLE PHYSICIANS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2012
-----------------------------------------------------
Last Update Date | 08/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 529 S JACKSON ST SUITE 416
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-3229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-852-7093
-----------------------------------------------------
Fax | 502-852-0886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 909
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40201-0909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-588-0320
-----------------------------------------------------
Fax | 502-588-0326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF HR
-----------------------------------------------------
Name | JOHN ELLIOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-588-4206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0007X
-----------------------------------------------------
Taxonomy Name | Molecular Genetic Pathology (Pathology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------