Basic Information
| Provider Information | |||||||||
| NPI: | 1639199557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DUPONT ANESTHESIA PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91345 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402910345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396100775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4004 DUPONT CIR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666317890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | COHEN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | M.D. | ||||||||
| AuthorizedOfficialTelephone: | 5028966428 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 23373 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | 23373 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 65918013 | 05 | KY | MEDICAID | 7100242240 | 05 | KY | MEDICAID |