Provider Demographics
NPI:1508358862
Name:BIROS, MARY KATHERINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:BIROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 S 4TH ST STE 700
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3046
Mailing Address - Country:US
Mailing Address - Phone:028-045-4955
Mailing Address - Fax:833-563-1715
Practice Address - Street 1:312 S 4TH ST STE 700
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3046
Practice Address - Country:US
Practice Address - Phone:502-804-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-03
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011457363L00000X, 363LG0600X, 363LP2300X, 363LA2200X
IN71010577363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
14388820OtherCAQH
IN300044749Medicaid
KY7100603430Medicaid