Basic Information
| Provider Information | |||||||||
| NPI: | 1538208384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERSON | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21249 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402210249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525875 | ||||||||
| FaxNumber: | 5028521754 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 S JACKSON ST | ||||||||
| Address2: | SUITE C07 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525875 | ||||||||
| FaxNumber: | 5028521754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 06/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 24249 | OK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 32652 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 32652 | KY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200048060A | 05 | OK | MEDICAID |