Basic Information
Provider Information | |||||||||
NPI: | 1730321845 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELLIS & BADENHAUSEN ORTHOPAEDICS, PSC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13151 MAGISTERIAL DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402234103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025871236 | ||||||||
FaxNumber: | 5025870126 | ||||||||
Practice Location | |||||||||
Address1: | 4123 DUTCHMANS LN STE 101 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402074718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025871236 | ||||||||
FaxNumber: | 5025870126 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2009 | ||||||||
LastUpdateDate: | 10/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FRACASSO | ||||||||
AuthorizedOfficialFirstName: | SARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING | ||||||||
AuthorizedOfficialTelephone: | 5025871236 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   | KY | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 207X00000X | 079020 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.