Basic Information
| Provider Information | |||||||||
| NPI: | 1740314541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | U OF L CHILDREN'S SLEEP MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 E GRAY ST STE 568 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028521297 | ||||||||
| FaxNumber: | 5028528556 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E BROADWAY STE 280 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028521297 | ||||||||
| FaxNumber: | 5028528556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5028521297 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080S0012X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65933384 | 05 | KY | MEDICAID |