Basic Information
Provider Information
NPI: 1336269117
EntityType: 2
ReplacementNPI:  
OrganizationName: DO NOT USE
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: BMA SURG
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2600 STANLEY GAULT PKWY
Address2: SUITE 201
City: LOUISVILLE
State: KY
PostalCode: 402234197
CountryCode: US
TelephoneNumber: 5022382801
FaxNumber: 5022382835
Practice Location
Address1: 2600 STANLEY GAULT PKWY
Address2: SUITE 201
City: LOUISVILLE
State: KY
PostalCode: 402234197
CountryCode: US
TelephoneNumber: 5022382801
FaxNumber: 5022382835
Other Information
ProviderEnumerationDate: 03/29/2007
LastUpdateDate: 08/03/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WORTLEY
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: EXECUTIVE DIRECTOR
AuthorizedOfficialTelephone: 5022382801
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: BAPTIST MEDICAL ASSOCIATES INC.
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X KYN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 
207Q00000X KYN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 
208D00000X KYN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansGeneral Practice 
208600000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansSurgery 

No ID Information.


Home