Basic Information
| Provider Information | |||||||||
| NPI: | 1700323987 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILLS MEDICAL PRACTICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN RESERVE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 N WHITTINGTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
| FaxNumber: | 5023942159 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 N WHITTINGTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2017 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/02/2019 | ||||||||
| NPIReactivationDate: | 08/29/2019 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHOBREY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | TYLER | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5026307249 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.