Basic Information
| Provider Information | |||||||||
| NPI: | 1952474785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUISVILLE GASTROENEROLOGY ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1169 EASTERN PKWY | ||||||||
| Address2: | G58 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024529567 | ||||||||
| FaxNumber: | 5024730586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1169 EASTERN PKWY | ||||||||
| Address2: | G58 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024529567 | ||||||||
| FaxNumber: | 5024730586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5024529567 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 65933897 | 05 | KY | MEDICAID |