Provider Demographics
NPI:1528036746
Name:ABRAMOVICH, MARK ALLAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLAN
Last Name:ABRAMOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:ALLAN
Other - Last Name:ABRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 W JOHN FITCH AVE
Mailing Address - Street 2:SUITE 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:SUITE 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
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0905702Medicare PIN