Basic Information
| Provider Information | |||||||||
| NPI: | 1295067411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY BECKER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4121 DUTCHMANS LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028968660 | ||||||||
| FaxNumber: | 5028965863 | ||||||||
| Practice Location | |||||||||
| Address1: | 4121 DUTCHMANS LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028968660 | ||||||||
| FaxNumber: | 5028965863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2010 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | SUMSER | ||||||||
| AuthorizedOfficialFirstName: | KAROLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5028968660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 2137P | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 1952305807 | 01 | KY | INDIVIDUAL NPI | OTHER |