Provider Demographics
NPI:1437188521
Name:SIEFERT, W. L. GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:W. L.
Middle Name:GREGORY
Last Name:SIEFERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5129 DIXIE HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-1727
Mailing Address - Country:US
Mailing Address - Phone:502-430-6223
Mailing Address - Fax:502-792-7272
Practice Address - Street 1:5129 DIXIE HWY STE 201
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1727
Practice Address - Country:US
Practice Address - Phone:502-430-6223
Practice Address - Fax:502-792-7272
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-044005207L00000X, 207LP2900X
KY46903207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64087653Medicaid
OH2413338Medicaid
INM22404018Medicare PIN
KYK135580Medicare PIN
OH2413338Medicaid