Basic Information
| Provider Information | |||||||||
| NPI: | 1528003316 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELIZABETHTOWN EMERGENCY PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950112 | ||||||||
| Address2: | DEPT. #52387 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884008870 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 913 N DIXIE AVE | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777836257 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | GILBERT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8884008870 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65935975 | 05 | KY | MEDICAID | 78902350 | 05 | KY | MEDICAID | 95900734 | 05 | KY | MEDICAID |