Provider Demographics
NPI:1194847871
Name:AMBROSIO, ROMEO S (MD)
Entity Type:Individual
Prefix:
First Name:ROMEO
Middle Name:S
Last Name:AMBROSIO
Suffix:
Gender:M
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:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:601 S FLOYD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1835
Practice Address - Country:US
Practice Address - Phone:502-629-1515
Practice Address - Fax:502-629-1545
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064174A207V00000X
KY41426207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
089399OtherSIHO
IN200894800Medicaid
KY7100005690Medicaid
VA0101238280OtherLICENSE
KY3873422OtherCIGNA
KY50015846OtherPASSPORT (OB/GYN)
LA2858785000OtherPASSPORT ADVNTG
KY50016558OtherPASSPORT - PCP
KY530495OtherANTHEM
000023028QOtherHUMANA
IN196290YYYOtherMEDICARE - CMA
KY0998872Medicare PIN