Provider Demographics
NPI:1558381830
Name:BUCHANAN, JERRY B (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:B
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:222 S 1ST ST
Mailing Address - Street 2:SUITE 501
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5404
Mailing Address - Country:US
Mailing Address - Phone:502-583-2731
Mailing Address - Fax:502-583-2733
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1818
Practice Address - Country:US
Practice Address - Phone:502-583-2731
Practice Address - Fax:502-583-2733
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY141272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02734476Medicaid
TX060793901Medicaid
CAXPY200542Medicaid
OH2126498Medicaid
KY64141278Medicaid
WV0160095000Medicaid
KY100321580OtherMANAGED HEALTH SERVICES
KY1054568Medicaid
IN100321580Medicaid
FL9097732-00Medicaid
KY000000062493OtherANTHEM BLUE FACET
KY100321580OtherMANAGED HEALTH SERVICES
KY2433693000Medicare ID - Type UnspecifiedPASSPORT ADVANTAGE
OH2126498Medicaid
KY64141278Medicaid