Basic Information
| Provider Information | |||||||||
| NPI: | 1265406987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHRADER | ||||||||
| FirstName: | ROBB | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3810 SPRINGHURST BLVD # 100 | ||||||||
| Address2: | MERIDIAN BUILDING | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402416100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028979881 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3810 SPRINGHURST BLVD # 100 | ||||||||
| Address2: | MERIDIAN BUILDING | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402416100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028979881 | ||||||||
| FaxNumber: | 5028979824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 26845 | KY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 26845 | 01 | KY | LICENSE NUMBER | OTHER | 6426845100 | 05 | KY | MEDICAID |