MEDICARE: LESLIE NUSSBAUM

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1427368588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE NUSSBAUM

Provider Business Mailing Address
First Line	:	101 W. MUHAMMAD ALI
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-1451
Country	:	US
Telephone Number	:	502-589-6000
Fax Number	:	502-589-8771

Provider Business Practice Location Address
First Line	:	3503 POPLAR LEVEL RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40213-1009
Country	:	US
Telephone Number	:	502-589-8600
Fax Number	:	502-589-8771

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2010
Last Update Date	:	12/01/2011

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Directions to “ LESLIE NUSSBAUM ” Practice Location

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