Basic Information
| Provider Information | |||||||||
| NPI: | 1760453518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOMMOR | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DEVON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY | ||||||||
| Address2: | STE 129 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534917 | ||||||||
| FaxNumber: | 5024895751 | ||||||||
| Practice Location | |||||||||
| Address1: | 4003 KRESGE WAY | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028971166 | ||||||||
| FaxNumber: | 5028971461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 27861 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000000652535 | 01 | KY | ANTHEM | OTHER | 64278617 | 05 | KY | MEDICAID | 3770421000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 50027652 | 01 | KY | PASSPORT | OTHER |