Provider Demographics
NPI:1487825519
Name:MARK A ABRAMOVICH MD
Entity Type:Organization
Organization Name:MARK A ABRAMOVICH MD
Other - Org Name:MARK A ABRAM MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ABRAMOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-348-7648
Mailing Address - Street 1:300 W JOHN FITCH AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1150
Mailing Address - Country:US
Mailing Address - Phone:502-348-7648
Mailing Address - Fax:502-348-7490
Practice Address - Street 1:300 W JOHN FITCH AVE
Practice Address - Street 2:STE 210
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1150
Practice Address - Country:US
Practice Address - Phone:502-348-7648
Practice Address - Fax:502-348-7490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64236912Medicaid
KY64236912Medicaid