1699775007 NPI number — CONNIE ANGGELIS MD

Table of content: CONNIE ANGGELIS MD (NPI 1699775007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699775007 NPI number — CONNIE ANGGELIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANGGELIS
Provider First Name:
CONNIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1699775007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 STANLEY GAULT PKWY STE 129
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:
40223-5176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-489-6613
Provider Business Mailing Address Fax Number:
502-489-5751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 KRESGE WAY STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-928-0900
Provider Business Practice Location Address Fax Number:
502-928-0901
Provider Enumeration Date:
07/28/2005

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: 207RC0000X , with the licence number:  27227 , 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: 64272271 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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