Basic Information
| Provider Information | |||||||||
| NPI: | 1619968013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUNNETT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | AMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024895730 | ||||||||
| FaxNumber: | 5024895753 | ||||||||
| Practice Location | |||||||||
| Address1: | 6580 KENWOOD CROSSING RD | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400147614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022433161 | ||||||||
| FaxNumber: | 5022433164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01062436A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 37781 | KY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 37781 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64069289 | 05 | KY | MEDICAID | 11199652 | 01 | CAOH | OTHER | 200857410A | 05 | IN | MEDICAID |