Provider Demographics
NPI:1386835007
Name:UNIVERSITY OF LOUISVILLE RESEARCH FOUNDATION, INC.
Entity Type:Organization
Organization Name:UNIVERSITY OF LOUISVILLE RESEARCH FOUNDATION, INC.
Other - Org Name:ULRF WINGS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF HEALTH AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:GANZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-852-5555
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0320
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:550 S JACKSON ST
Practice Address - Street 2:ACB 2ND FLOOR
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1622
Practice Address - Country:US
Practice Address - Phone:502-561-8844
Practice Address - Fax:502-589-5093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50020689OtherPASSPORT HEALTH PLAN
KY1700115800 (PAS)Medicaid
IN200925390Medicaid
KY522843OtherANTHEM
KY7100083550 (MDS)Medicaid
KY3541914000OtherPASSPORT ADVANTAGE
IN200925390Medicaid