Basic Information
| Provider Information | |||||||||
| NPI: | 1952532665 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF LOUISVILLE RESEARCH FOUNDATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHILDREN AND YOUTH DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 555 S FLOYD ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525588 | ||||||||
| FaxNumber: | 5028525630 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 S FLOYD ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525588 | ||||||||
| FaxNumber: | 5028525630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2009 | ||||||||
| LastUpdateDate: | 09/02/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MINGUS | ||||||||
| AuthorizedOfficialFirstName: | LEE ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5028525588 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 45659976 | 05 | KY | MEDICAID |