Provider Demographics
NPI:1225327174
Name:DIEBOLD, SARA GREENE
Entity Type:Individual
Prefix:MISS
First Name:SARA
Middle Name:GREENE
Last Name:DIEBOLD
Suffix:
Gender:F
Credentials:
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 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-272-5754
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:3840 RUCKRIEGEL PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6835
Practice Address - Country:US
Practice Address - Phone:502-261-7227
Practice Address - Fax:502-261-7157
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY47488208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100315080Medicaid
KY000000897766OtherANTHEM
KY50077879OtherPASSPORT HEALTH PLAN
KYK360020OtherKY MEDICARE