1013041391 NPI number — UNIVERSITY OF LOUISVILLE

Table of content: (NPI 1013041391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013041391 NPI number — UNIVERSITY OF LOUISVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF LOUISVILLE
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:
MAXILLOFACIAL ONCOLOGIC DENTISTRY
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:
1013041391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
529 S JACKSON ST
Provider Second Line Business Mailing Address:
# 127
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-3229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-852-5747
Provider Business Mailing Address Fax Number:
502-852-6132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
529 S JACKSON ST
Provider Second Line Business Practice Location Address:
# 127
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-3229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-852-5747
Provider Business Practice Location Address Fax Number:
502-852-6132
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KHAN
Authorized Official First Name:
ZAFRULLA
Authorized Official Middle Name:
Authorized Official Title or Position:
PROSTHODONTICS
Authorized Official Telephone Number:
502-852-5747

Provider Taxonomy Codes

  • Taxonomy code: 284300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100018200 . This is a "INDIANA MEDICAID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 775656 . This is a "UNITED CONN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2438647000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 190005666 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 60050671 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0003831 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000175275 . This is a "ANTHEM BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5651497 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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