Basic Information
| Provider Information | |||||||||
| NPI: | 1801110424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAUFFMAN | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | L. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 12955 SHELBYVILLE RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022454301 | ||||||||
| FaxNumber: | 5022445829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2010 | ||||||||
| LastUpdateDate: | 05/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 46193 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000829906 | 01 | KY | ANTHEM - NCMA | OTHER | 149563 | 01 | KY | SIHO - NCMA | OTHER | 50065676 | 01 | KY | PASSPORT | OTHER | 000000830890 | 01 | KY | ANTHEM - NICC | OTHER | 149534 | 01 | KY | SIHO - NICC | OTHER | 7100179250 | 05 | KY | MEDICAID |