=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992011050
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MD2U KENTUCKY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2010
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9200 SHELBYVILLE RD STE 530
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40222-5144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-327-9100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9200 SHELBYVILLE RD STE 530
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40222-5144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-327-9100
-----------------------------------------------------
Fax | 502-742-3767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL COUNSEL
-----------------------------------------------------
Name | KRISTEN LEIGH MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-327-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------