Basic Information
| Provider Information | |||||||||
| NPI: | 1356018519 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOUISVILLE OBSERVATIONAL MEDICINE ASSOCIATES PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 778730 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606778730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022154229 | ||||||||
| FaxNumber: | 9042658181 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 KRESGE WAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028978100 | ||||||||
| FaxNumber: | 9042658181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2021 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | HOLLAND | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5028978100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.