Basic Information
| Provider Information | |||||||||
| NPI: | 1427037076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEADLE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025880329 | ||||||||
| FaxNumber: | 5025880326 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | SUITE 710 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025838303 | ||||||||
| FaxNumber: | 5025840302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 08/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 21560 | KY | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 21560 | KY | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 100345350A | 05 | IN | MEDICAID | 1051079 | 01 | KY | PASSPORT | OTHER | 64215601 | 05 | KY | MEDICAID |