Provider Demographics
NPI:1568622314
Name:EAST LOUISVILLE NEUROLOGY, PSC
Entity Type:Organization
Organization Name:EAST LOUISVILLE NEUROLOGY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-4014
Mailing Address - Street 1:PO BOX 23568
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223
Mailing Address - Country:US
Mailing Address - Phone:502-245-4014
Mailing Address - Fax:502-245-4015
Practice Address - Street 1:13806 LAKE POINT CIRCLE
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223
Practice Address - Country:US
Practice Address - Phone:502-254-4014
Practice Address - Fax:502-254-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2084N0400X174400000X
KY324112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64324114Medicaid
KY1788801Medicare PIN
KY64324114Medicaid