1508868753 NPI number — DR. VINCENT C LUSCO III M.D.

Table of content: DR. VINCENT C LUSCO III M.D. (NPI 1508868753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508868753 NPI number — DR. VINCENT C LUSCO III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUSCO
Provider First Name:
VINCENT
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1508868753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E LIBERTY ST STE 800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-1428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-366-1090
Provider Business Mailing Address Fax Number:
502-366-1564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4402 CHURCHMAN AVE
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40215-3101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-366-1090
Provider Business Practice Location Address Fax Number:
502-366-1564
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  34952 , 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: 000000289651 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200397600 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64069636 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50001240 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00017648 . This is a "RAILROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P01040544 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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