Basic Information
| Provider Information | |||||||||
| NPI: | 1861435984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUNLEY | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6749 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402060749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028997646 | ||||||||
| FaxNumber: | 5028997648 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 KRESGE WAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028978100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 22415 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000350651 | 01 | BLUE CROSS FACET ID | OTHER |