1609194596 NPI number — DR. CHRISTINA BLUME CLARK M.D., PH.D.

Table of content: DR. CHRISTINA BLUME CLARK M.D., PH.D. (NPI 1609194596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609194596 NPI number — DR. CHRISTINA BLUME CLARK M.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CHRISTINA
Provider Middle Name:
BLUME
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIEGAND
Provider Other First Name:
CHRISTINA
Provider Other Middle Name:
LOUISE BLUME
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609194596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT. OF RADIOLOGY UNIVERSITY OF LOUISVILLE HOSPITAL
Provider Second Line Business Mailing Address:
530 SOUTH JACKSON STREET, CCB-C07
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-852-5875
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DEPARTMENT OF RADIOLOGY UNIVERSITY OF LOUISVILLE HOSP.
Provider Second Line Business Practice Location Address:
530 SOUTH JACKSON STREET CCB-C07
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-852-5875
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2010

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: 2085R0202X , with the licence number:  50602 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: MD461741 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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