Provider Demographics
NPI:1225327513
Name:MCCRACKEN, ROBERT RUSSELL
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RUSSELL
Last Name:MCCRACKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 KRESGE WAY
Mailing Address - Street 2:SUITE 308
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4637
Mailing Address - Country:US
Mailing Address - Phone:502-895-9627
Mailing Address - Fax:502-895-8977
Practice Address - Street 1:4000 KRESGE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4605
Practice Address - Country:US
Practice Address - Phone:502-895-8911
Practice Address - Fax:502-895-8977
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47267207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK151940Medicare PIN