Basic Information
| Provider Information | |||||||||
| NPI: | 1124281167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | TYRUS | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 COMMERCE CROSSINGS DR FL FLOOR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402292182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534924 | ||||||||
| FaxNumber: | 5024895750 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 TRILLIUM WAY | ||||||||
| Address2: | BAPTIST HEALTH CANCER CENTER | ||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065231934 | ||||||||
| FaxNumber: | 6065231982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 42601 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 7100160280 | 05 | KY | MEDICAID | P01428671 | 01 | KY | RR MEDICARE | OTHER |