1790191161 NPI number — MORRIS MEDICAL GROUP OF LOUISVILLE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790191161 NPI number — MORRIS MEDICAL GROUP OF LOUISVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MORRIS MEDICAL GROUP OF LOUISVILLE
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:
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:
1790191161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1941 BISHOP LN
Provider Second Line Business Mailing Address:
#508
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40218-1922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-739-7641
Provider Business Mailing Address Fax Number:
817-288-0758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1941 BISHOP LN
Provider Second Line Business Practice Location Address:
#508
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40218-1922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-451-0484
Provider Business Practice Location Address Fax Number:
502-451-0778
Provider Enumeration Date:
07/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
WALTER
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
817-739-7641

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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