MEDICARE: DO NOT USE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	207R00000X	Internal Medicine Physician	KY
2	207Q00000X	Family Medicine Physician	KY
3	208D00000X	General Practice Physician	KY
4	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1336269117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DO NOT USE

Provider Business Mailing Address
First Line	:	2600 STANLEY GAULT PKWY
Second Line	:	SUITE 201
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-4197
Country	:	US
Telephone Number	:	502-238-2801
Fax Number	:	502-238-2835

Provider Business Practice Location Address
First Line	:	2600 STANLEY GAULT PKWY
Second Line	:	SUITE 201
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-4197
Country	:	US
Telephone Number	:	502-238-2801
Fax Number	:	502-238-2835

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JOHN WORTLEY
Credential	:
Telephone Number	:	502-238-2801

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	08/03/2010

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Directions to “DO NOT USE ” Practice Location

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