Provider Demographics
NPI:1235329400
Name:THAD R. SCHULTEN PSC
Entity Type:Organization
Organization Name:THAD R. SCHULTEN PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-361-0134
Mailing Address - Street 1:4515 CHURCHMAN AVE.
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215
Mailing Address - Country:US
Mailing Address - Phone:502-361-0134
Mailing Address - Fax:502-361-0137
Practice Address - Street 1:4515 CHURCHMAN AVE.
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-361-0134
Practice Address - Fax:502-361-0137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65941114Medicaid
KY65941114Medicaid