1700879095 NPI number — DR. CHRISTOPHER E NOONAN DMD MD

Table of content: DR. CHRISTOPHER E NOONAN DMD MD (NPI 1700879095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700879095 NPI number — DR. CHRISTOPHER E NOONAN DMD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOONAN
Provider First Name:
CHRISTOPHER
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD MD
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:
1700879095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 CANNONS LN
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-454-4885
Provider Business Mailing Address Fax Number:
502-452-1926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 ABRAHAM FLEXNER WAY
Provider Second Line Business Practice Location Address:
STE 302
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-587-7874
Provider Business Practice Location Address Fax Number:
502-587-0758
Provider Enumeration Date:
08/23/2005

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: 204E00000X , with the licence number:  MD-39508 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 7486 , 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: 200521540 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60003274 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000364871 . This is a "BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64098635 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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