Basic Information
| Provider Information | |||||||||
| NPI: | 1578576690 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MD2U PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MD2U DOCTORS WHO MAKE HOUSE CALLS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 CRESCENT AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402061525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 5027423767 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 CRESCENT AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402061525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 5027423767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | LATTA | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5023279100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 01056286A | IN | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QP2300X | 38836 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 000000365262 | 01 | KY | BCBS PIN | OTHER | DD3382 | 01 | KY | RAILROAD MEDICARE PIN | OTHER | 50007387 | 01 | KY | PASSPORT # | OTHER | 2448540000 | 01 | KY | PASSPORT ADVANTAGE # | OTHER | 7100037890 | 05 | KY | MEDICAID |