Basic Information
| Provider Information | |||||||||
| NPI: | 1467568162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LOUISVILLE BONE & JOINT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635191 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138912813 | ||||||||
| FaxNumber: | 5137931032 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E GRAY ST | ||||||||
| Address2: | STE 701 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025626021 | ||||||||
| FaxNumber: | 5025626039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 06/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | KHALILY | ||||||||
| AuthorizedOfficialFirstName: | CYNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/ PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5025626021 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | DE4059 | 01 | RR MEDICARE | OTHER | 50001642 | 01 | KY | PASSPORT | OTHER | 2443212000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 7100037410 | 05 | KY | MEDICAID | 200443290A | 05 | IN | MEDICAID |