Provider Demographics
NPI:1295852317
Name:LOUISVILLE ENDOCRINOLOGY PSC
Entity Type:Organization
Organization Name:LOUISVILLE ENDOCRINOLOGY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-515-6621
Mailing Address - Street 1:3288 ILLINOIS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213
Mailing Address - Country:US
Mailing Address - Phone:502-515-6621
Mailing Address - Fax:502-515-6620
Practice Address - Street 1:3288 ILLINOIS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213
Practice Address - Country:US
Practice Address - Phone:502-515-6621
Practice Address - Fax:502-515-6620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY26476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000227457OtherANTHEM
1162678OtherPASSPORT
2439678000OtherPASSPORT ADVANTAGE
E99765Medicare UPIN
2439678000OtherPASSPORT ADVANTAGE