Provider Demographics
NPI:1124037114
Name:LOUISVILLE WOUND CARE ASSOCIATES PSC
Entity Type:Organization
Organization Name:LOUISVILLE WOUND CARE ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCMILLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-777-9961
Mailing Address - Street 1:2100 GARDINER LN STE 207
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2948
Mailing Address - Country:US
Mailing Address - Phone:502-777-9961
Mailing Address - Fax:502-379-8791
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-777-9961
Practice Address - Fax:502-379-8791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23946207VG0400X
KY18435208600000X
KY3003616363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201260300Medicaid
KY000000486840OtherANTHEM
KY65945933Medicaid
KY50012570OtherPASSPORT
KY78905221Medicaid
KY65945933Medicaid
KY78905221Medicaid
IN201260300Medicaid