Provider Demographics
NPI:1407934730
Name:GREATER LOUISVILLE ANESTHESIA SERVICES--DOWNTOWN
Entity Type:Organization
Organization Name:GREATER LOUISVILLE ANESTHESIA SERVICES--DOWNTOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAVERTY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:502-568-4800
Mailing Address - Street 1:3401 BROECK POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2531
Mailing Address - Country:US
Mailing Address - Phone:502-568-4800
Mailing Address - Fax:502-222-8647
Practice Address - Street 1:444 S 1ST ST
Practice Address - Street 2:C/O AESTHETIC PLASTIC SURGERY INSTITUTE
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1416
Practice Address - Country:US
Practice Address - Phone:502-568-4800
Practice Address - Fax:502-222-8647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1089893/2802A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74900150Medicaid
KY74900150Medicaid