Basic Information
| Provider Information | |||||||||
| NPI: | 1710164447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONE MARROW TRANSPLANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S FLOYD ST | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026297750 | ||||||||
| FaxNumber: | 5026297784 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S FLOYD ST | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026297750 | ||||||||
| FaxNumber: | 5026297784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | BERTOLONE | ||||||||
| AuthorizedOfficialFirstName: | SALVATORE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5026297750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BONE MARROW TRANSPLANT | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0200X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 78905189 | 05 | KY | MEDICAID |