Basic Information
Provider Information | |||||||||
NPI: | 1780678763 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NETT | ||||||||
FirstName: | CARRILEA | ||||||||
MiddleName: | REED | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 776351 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606776351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022725395 | ||||||||
FaxNumber: | 5022725339 | ||||||||
Practice Location | |||||||||
Address1: | 4915 NORTON HEALTHCARE BLVD STE 203 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402412861 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5024239595 | ||||||||
FaxNumber: | 5027190161 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2005 | ||||||||
LastUpdateDate: | 09/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 38809 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 50005048 | 01 | KY | PASSPORT | OTHER | 000057120M | 01 | KY | HUMANA - WS | OTHER | 127026 | 01 | KY | SIHO - WS | OTHER | 65925109 | 01 | KY | MEDICAID GRP | OTHER | 1147806 | 01 | KY | CIGNA-WS | OTHER | NE64083835 | 05 | KY |   | MEDICAID | 000000724267 | 01 | KY | ANTHEM - WS | OTHER | 201040580 | 05 | IN |   | MEDICAID | 64083835 | 05 | KY |   | MEDICAID | 50034481 | 01 | KY | PASSPORT - WS | OTHER | 5581 | 01 | KY | MEDICARE GRP | OTHER |