Individual
NEMR S EID
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
411 E CHESTNUT ST # 5A6B, LOUISVILLE, KY 40202-1713
(502) 588-4940
(502) 588-7712
Mailing address
PO BOX 776879, CHICAGO, IL 60677-6879
(502) 272-5817
(502) 272-5339
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
25574
KY
2080P0214X
Pediatric Pulmonology Physician
Primary
25574
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100376780
—
IN
01
—
25574
STATE LICENSE
KY
05
—
64255748
—
KY
Enumeration date
12/05/2005
Last updated
05/25/2022
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