Provider Demographics
NPI:1316031453
Name:REICHERT, MARY LOU G (MD)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:G
Last Name:REICHERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:6041 TIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8134
Practice Address - Country:US
Practice Address - Phone:502-928-0910
Practice Address - Fax:502-928-0911
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY21498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64214984Medicaid
KY64214984Medicaid
KY080144744Medicare PIN
A80435Medicare UPIN