MEDICARE: LOUISVILLE SURGICAL ASSOCIATES, PSC

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	208600000X	Surgery Physician		KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CN1016	OTHER	KY	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000060149	OTHER	KY	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1049011	OTHER	KY	PASSPORT

General Provider Information

NPI Number	:	1770575516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISVILLE SURGICAL ASSOCIATES, PSC

Provider Business Mailing Address
First Line	:	4402 CHURCHMAN AVE
Second Line	:	SUITE 202
City	:	LOUISVILLE
State	:	KY
Zip	:	40215-1190
Country	:	US
Telephone Number	:	502-366-1090
Fax Number	:	502-366-1564

Provider Business Practice Location Address
First Line	:	4402 CHURCHMAN AVE
Second Line	:	SUITE 202
City	:	LOUISVILLE
State	:	KY
Zip	:	40215-1190
Country	:	US
Telephone Number	:	502-366-1090
Fax Number	:	502-366-1564

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. TERRI L WILLETT
Credential	:
Telephone Number	:	502-366-1090

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	10/21/2010

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