Basic Information
| Provider Information | |||||||||
| NPI: | 1629075825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF LOUISVILLE RESEARCH FOUNDATION, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KIDNEY DISEASE PROGRAM / LOUISVILLE RENAL DIALYSIS FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 615 S PRESTON ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525757 | ||||||||
| FaxNumber: | 5028524039 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 S PRESTON ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525757 | ||||||||
| FaxNumber: | 5028524039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEDERER | ||||||||
| AuthorizedOfficialFirstName: | ELEANOR | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF, DIVISION OF NEPHROLOGY | ||||||||
| AuthorizedOfficialTelephone: | 5028525757 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 182501 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 100003040A | 01 | IN | INDIANA MEDICAID | OTHER | 39090030 | 05 | KY | MEDICAID | 000003108H | 01 | KY | HUMANA HEALTH CARE NUMBER | OTHER | 004541476 | 01 | KY | AETNA PROVIDER # | OTHER | 50001023 | 05 | KY | MEDICAID | 5416V4981 | 01 | KY | AHDS PROVIDER # | OTHER | 000000112462 | 01 | KY | BCBS 12 DIGIT PROVIDER # | OTHER | 350 | 01 | KY | BLUE CROSS NUMBER | OTHER |