Provider Demographics
NPI:1215182951
Name:WOMENS CENTER FOR GYNECOLOGY AND BLADDER DISORDERS
Entity Type:Organization
Organization Name:WOMENS CENTER FOR GYNECOLOGY AND BLADDER DISORDERS
Other - Org Name:THE WOMEN'S CENTER FOR GYNECOLOGY AND BLADDER DISORDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:EKLUND
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:502-239-9920
Mailing Address - Street 1:5512 BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-1910
Mailing Address - Country:US
Mailing Address - Phone:502-239-9920
Mailing Address - Fax:
Practice Address - Street 1:5512 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-1910
Practice Address - Country:US
Practice Address - Phone:502-239-9920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1777P & 3074P363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00839Medicare PIN