Basic Information
| Provider Information | |||||||||
| NPI: | 1689670606 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEWISH HOSPITAL & ST. MARY'S HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FRAZIER REHAB INSTITUTE FERN VALLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2587 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402012587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025874099 | ||||||||
| FaxNumber: | 5025874944 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HIGH RISE DR | ||||||||
| Address2: | STE 110 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402133251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029664466 | ||||||||
| FaxNumber: | 5029643271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 05/18/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPALDING | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5025827437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JEWISH HOSPITAL & ST. MARY'S HEALTHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 273Y00000X | 100658 | KY | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 000000063934 | 01 | KY | ANTHEM | OTHER | 0696831 | 01 | KY | AETNA HMO | OTHER |