Basic Information
| Provider Information | |||||||||
| NPI: | 1174500318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAKUTT | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | MITCHELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950195 | ||||||||
| Address2: | DEPT 86236 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024732100 | ||||||||
| FaxNumber: | 5024596461 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 AUDUBON PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026367449 | ||||||||
| FaxNumber: | 5026367950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 28051 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 64280514 | 05 | KY | MEDICAID |