1124064225 NPI number — MICHAEL DAVIS MD

Table of content: NICOLE GERCHELLE YAMIO ARBUES (NPI 1174319628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124064225 NPI number — MICHAEL DAVIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1124064225
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950248
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:
40295-0248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-489-5730
Provider Business Mailing Address Fax Number:
502-489-5733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12010 SHELBYVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40243-1054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-897-9191
Provider Business Practice Location Address Fax Number:
502-897-7626
Provider Enumeration Date:
06/20/2006

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: 207R00000X , with the licence number:  26497 , 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: 000000500017 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 6426497100 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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