Organization
LOUISVILLE SURGICAL ASSOCIATES, PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TERRI L WILLETT (OFFICE MANAGER)
(502) 366-1090
Entity
Organization
Contact information
Practice address
4402 CHURCHMAN AVE, SUITE 202, LOUISVILLE, KY 40215-1190
(502) 366-1090
(502) 366-1564
Mailing address
4402 CHURCHMAN AVE, SUITE 202, LOUISVILLE, KY 40215-1190
(502) 366-1090
(502) 366-1564
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
—
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000060149
ANTHEM
KY
01
—
1049011
PASSPORT
KY
05
—
65920985
—
KY
01
—
CN1016
RAILROAD MEDICARE
KY
Enumeration date
08/18/2005
Last updated
10/21/2010
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