1184760357 NPI number — LOUISVILLE NEUROSURGICAL SPECIALIST PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184760357 NPI number — LOUISVILLE NEUROSURGICAL SPECIALIST PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUISVILLE NEUROSURGICAL SPECIALIST PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184760357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4010 DUPONT CIR
Provider Second Line Business Mailing Address:
SUITE L28
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40207-4812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-899-9099
Provider Business Mailing Address Fax Number:
502-899-9899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4010 DUPONT CIR
Provider Second Line Business Practice Location Address:
SUITE L28
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-899-9099
Provider Business Practice Location Address Fax Number:
502-899-9899
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PETRUSKA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
502-899-9099

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  24702 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50001903 . This is a "PASSPORT ID" identifier . This identifiers is of the category "OTHER".




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