Provider Demographics
NPI:1083970347
Name:VINCI, SUSAN BERSOT (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BERSOT
Last Name:VINCI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12912 DEER CROSS DR
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8118
Mailing Address - Country:US
Mailing Address - Phone:773-343-1996
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1886
Practice Address - Country:US
Practice Address - Phone:502-587-4404
Practice Address - Fax:502-587-4156
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49408207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100249990 (KOHMG)Medicaid
IN201384650A (KOHMG)Medicaid
KY7100249990 (KOHMG)Medicaid
KYK203600 (KOHMG)Medicare PIN