1801110424 NPI number — SHAWNA L. KAUFFMAN

Table of content: SHAWNA L. KAUFFMAN (NPI 1801110424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801110424 NPI number — SHAWNA L. KAUFFMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAUFFMAN
Provider First Name:
SHAWNA
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1801110424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950202
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:
40295-0202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12955 SHELBYVILLE RD STE 2
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:
40243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-245-4301
Provider Business Practice Location Address Fax Number:
502-244-5829
Provider Enumeration Date:
03/25/2010

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 46193 , 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: 000000829906 . This is a "ANTHEM - NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 149563 . This is a "SIHO - NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50065676 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000830890 . This is a "ANTHEM - NICC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 149534 . This is a "SIHO - NICC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100179250 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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