Basic Information
Provider Information | |||||||||
NPI: | 1801873617 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELIN | ||||||||
FirstName: | RONALD | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22214 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402520214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028521648 | ||||||||
FaxNumber: | 5028522046 | ||||||||
Practice Location | |||||||||
Address1: | 530 S JACKSON ST | ||||||||
Address2: | DEPARTMENT OF PATHOLOGY & LAB MEDICINE | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402021675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028524464 | ||||||||
FaxNumber: | 5028521761 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 09/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZM0300X | 33254 | KY | N |   | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | 207ZP0102X | 33254 | KY | N |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0104X | 33254 | KY | Y |   | Allopathic & Osteopathic Physicians | Pathology | Chemical Pathology |
ID Information
ID | Type | State | Issuer | Description | 1050558 | 01 | KY | PASSPORT-KY MED MG CARE | OTHER | 64-332547 | 01 | KY | MEDICAID | OTHER | 200212190 | 05 | IN |   | MEDICAID |