Basic Information
| Provider Information | |||||||||
| NPI: | 1417902925 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025894856 | ||||||||
| FaxNumber: | 5025895093 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT STREET | ||||||||
| Address2: | STE 310 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025894856 | ||||||||
| FaxNumber: | 5025895093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | SNAWDER | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5025894856 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65902447 | 05 | KY | MEDICAID | 100003580 | 05 | IN | MEDICAID |