Basic Information
| Provider Information | |||||||||
| NPI: | 1386835007 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF LOUISVILLE RESEARCH FOUNDATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ULRF WINGS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025880320 | ||||||||
| FaxNumber: | 5022175056 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 S JACKSON ST | ||||||||
| Address2: | ACB 2ND FLOOR | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025618844 | ||||||||
| FaxNumber: | 5025895093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GANZEL | ||||||||
| AuthorizedOfficialFirstName: | TONI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF HEALTH AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 5028525555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/21/2021 | ||||||||
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 | 207RI0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 50020689 | 01 | KY | PASSPORT HEALTH PLAN | OTHER | 1700115800 (PAS) | 05 | KY | MEDICAID | 200925390 | 05 | IN | MEDICAID | 522843 | 01 | KY | ANTHEM | OTHER | 7100083550 (MDS) | 05 | KY | MEDICAID | 3541914000 | 01 | KY | PASSPORT ADVANTAGE | OTHER |