1740627108 NPI number — DR. ANDREW MICHAEL LALLY M.D.

Table of content: DR. ANDREW MICHAEL LALLY M.D. (NPI 1740627108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740627108 NPI number — DR. ANDREW MICHAEL LALLY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LALLY
Provider First Name:
ANDREW
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1740627108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 S JACKSON ST
Provider Second Line Business Mailing Address:
ACB, 3RD FLOOR MEDICINE OFFICE
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-1622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-852-5666
Provider Business Mailing Address Fax Number:
502-852-8980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3532 EPHRAIM MCDOWELL DR
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:
40205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-456-6200
Provider Business Practice Location Address Fax Number:
502-456-6655
Provider Enumeration Date:
05/25/2013

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: 207RH0002X , with the licence number:  49076 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 49076 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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