MEDICARE: A BERT SPARROW 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	13980	KY
2	2086S0129X	Vascular Surgery Physician	13980	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	022087143	OTHER	KY	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1048991	OTHER	KY	PASSPORT
3	000000045552	OTHER		BLUE CROSS BLUE SHIELD
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	2432327000	OTHER	KY	PASSPORT ADVANTAGE

General Provider Information

NPI Number	:	1942230578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A BERT SPARROW PSC

Provider Business Mailing Address
First Line	:	4402 CHURCHMAN AVE
Second Line	:	STE 211
City	:	LOUISVILLE
State	:	KY
Zip	:	40215-3100
Country	:	US
Telephone Number	:	502-361-6075
Fax Number	:	502-361-6071

Provider Business Practice Location Address
First Line	:	4402 CHURCHMAN AVE
Second Line	:	STE 211
City	:	LOUISVILLE
State	:	KY
Zip	:	40215-3100
Country	:	US
Telephone Number	:	502-361-6075
Fax Number	:	502-361-6071

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ATHEL BERT SPARROW
Credential	:	M.D.
Telephone Number	:	502-361-6075

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	04/24/2008

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Directions to “A BERT SPARROW PSC ” Practice Location

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