1578576690 NPI number — MD2U PLLC

Table of content: (NPI 1578576690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578576690 NPI number — MD2U PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MD2U PLLC
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:
MD2U DOCTORS WHO MAKE HOUSE CALLS
Provider Other Organization Name Type Code:
5
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:
1578576690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 CRESCENT AVE
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:
40206-1525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-327-9100
Provider Business Mailing Address Fax Number:
502-742-3767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 CRESCENT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40206-1525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-327-9100
Provider Business Practice Location Address Fax Number:
502-742-3767
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LATTA
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
502-327-9100

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  38836 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X , with the licence number: 01056286A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000000365262 . This is a "BCBS PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: DD3382 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50007387 . This is a "PASSPORT #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2448540000 . This is a "PASSPORT ADVANTAGE #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100037890 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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