Basic Information
| Provider Information | |||||||||
| NPI: | 1225327174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIEBOLD | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | GREENE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776879 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725754 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Practice Location | |||||||||
| Address1: | 3840 RUCKRIEGEL PKWY | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402996835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022617227 | ||||||||
| FaxNumber: | 5022617157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 47488 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100315080 | 05 | KY | MEDICAID | 000000897766 | 01 | KY | ANTHEM | OTHER | 50077879 | 01 | KY | PASSPORT HEALTH PLAN | OTHER | K360020 | 01 | KY | KY MEDICARE | OTHER |