Provider Demographics
NPI:1023187234
Name:MOBILE MD HOLDINGS LLC
Entity Type:Organization
Organization Name:MOBILE MD HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-253-4140
Mailing Address - Street 1:9510 ORMSBY STATION RD
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4081
Mailing Address - Country:US
Mailing Address - Phone:502-253-4140
Mailing Address - Fax:502-253-4144
Practice Address - Street 1:9510 ORMSBY STATION ROAD
Practice Address - Street 2:SUITE 100B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4082
Practice Address - Country:US
Practice Address - Phone:502-253-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY720224207QG0300X
363LA2200X
KY363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65944530Medicaid
KY78904810Medicaid
KY65944530Medicaid