Basic Information
| Provider Information | |||||||||
| NPI: | 1285654053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YUSSMAN | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | AARON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025880329 | ||||||||
| FaxNumber: | 5025880326 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | STE 410 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025884400 | ||||||||
| FaxNumber: | 5025884401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 13044 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207V00000X | 13044 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 64130446 | 05 | KY | MEDICAID | 1049351 | 01 | KY | PASSPORT PCP | OTHER | 50004028 | 01 | KY | PASSPORT SPECIALITY | OTHER | 100333900 | 05 | IN | MEDICAID | 000000047610 | 01 | KY | ANTHEM | OTHER |