Basic Information
Provider Information | |||||||||
NPI: | 1861499576 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEVERTSON | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6420 DUTCHMANS PKWY | ||||||||
Address2: | 380 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402053372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028948441 | ||||||||
FaxNumber: | 5028944453 | ||||||||
Practice Location | |||||||||
Address1: | 6420 DUTCHMANS PKWY | ||||||||
Address2: | 380 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402053372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028948441 | ||||||||
FaxNumber: | 5028944453 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 01/12/2017 | ||||||||
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 | 207Y00000X | 34466 | KY | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Y00000X | 01049174 | IN | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207YX0901X | 34466 | KY | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology | 207YX0901X | 01049174 | IN | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology |
ID Information
ID | Type | State | Issuer | Description | 000000045447 | 01 | KY | ANTHEM FACET NUMBER | OTHER | 040012436 | 01 | KY | RAIL ROAD MEDICARE | OTHER | 64344666 | 05 | KY |   | MEDICAID | 200175990A | 05 | IN |   | MEDICAID |