Basic Information
Provider Information | |||||||||
NPI: | 1295932366 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOZEMAN | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9800 SHELBYVILLE RD | ||||||||
Address2: | SUITE #220 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402232992 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5024298585 | ||||||||
FaxNumber: | 8556567325 | ||||||||
Practice Location | |||||||||
Address1: | 971 SOUTH HIGHWAY 27 | ||||||||
Address2: |   | ||||||||
City: | SOMERSET | ||||||||
State: | KY | ||||||||
PostalCode: | 42003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6064510239 | ||||||||
FaxNumber: | 8556567325 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2007 | ||||||||
LastUpdateDate: | 03/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 03375 | KY | Y |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   |
ID Information
ID | Type | State | Issuer | Description | 50034391 | 01 | KY | PASSPORT | OTHER | 7100172180 | 05 | KY |   | MEDICAID | 000000726124 | 01 |   | ANTHEM | OTHER | P01049647 | 01 | KY | MEDICARE RAILROAD | OTHER |