Basic Information
| Provider Information | |||||||||
| NPI: | 1275539801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950116 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5022133853 | ||||||||
| Practice Location | |||||||||
| Address1: | 2944 BRECKENRIDGE LN | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402201409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5022133853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 32102 | KY | N | Other Service Providers | Specialist | 207Y00000X | 01054760A | IN | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 32102 | KY | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 080161658 | 01 | MEDICARE RAIL ROAD | OTHER | 200345040 | 05 | IN | MEDICAID | 64013378 | 05 | KY | MEDICAID |