Basic Information
Provider Information | |||||||||
NPI: | 1194949024 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EVERSOLE | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2549 DELL RD | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402052309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5024543000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 200 HIGH RISE DR | ||||||||
Address2: | STE 374 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402133252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5029696552 | ||||||||
FaxNumber: | 5029693799 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2007 | ||||||||
LastUpdateDate: | 08/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32450 | KY | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207P00000X | 32450 | KY | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00533022 | 01 | KY | MEDICARE - NORTON | OTHER | 009583 | 01 | KY | SIHO - NORTON | OTHER | P00612408 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000546227 | 01 | KY | ANTHEM - NORTON | OTHER |