1679017552 NPI number — NORTON CLARK PHYSICIAN PRACTICES, LLC

Table of content: (NPI 1679017552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679017552 NPI number — NORTON CLARK PHYSICIAN PRACTICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTON CLARK PHYSICIAN PRACTICES, LLC
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:
HAVENS MEDICAL GROUP
Provider Other Organization Name Type Code:
3
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:
1679017552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4803 OLYMPIA PARK PLZ STE 1100
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:
40241-3009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2205 GREENTREE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47129-8957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-283-4441
Provider Business Practice Location Address Fax Number:
812-288-2605
Provider Enumeration Date:
12/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GAST
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP MANAGED CARE
Authorized Official Telephone Number:
502-559-9409

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  28168470A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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