Provider Demographics
NPI:1528209350
Name:UNIVERSITY OF LOUISVILLE
Entity Type:Organization
Organization Name:UNIVERSITY OF LOUISVILLE
Other - Org Name:CHILDREN AND YOUTH PROJECT-ADOLESCENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:RABALAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-852-8600
Mailing Address - Street 1:PO BOX 2469
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-2469
Mailing Address - Country:US
Mailing Address - Phone:502-852-8500
Mailing Address - Fax:502-852-8556
Practice Address - Street 1:555 S FLOYD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3822
Practice Address - Country:US
Practice Address - Phone:502-852-5588
Practice Address - Fax:502-852-5630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY297102080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64067259Medicaid