Basic Information
| Provider Information | |||||||||
| NPI: | 1952382814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLAYBON | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 258 | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | INDEPENDENT ANESTHESIOLOGISTS PSC | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 02/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 23831 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 10757061 | 01 | CAQH | OTHER | 64032659 | 05 | KY | MEDICAID | 000000362175 | 01 | ANTHEM BLUE SHIELD | OTHER | 0486595 | 05 | OH | MEDICAID | 4038729 | 01 | AETNA | OTHER |