Provider Demographics
NPI:1659391563
Name:LOUISVILLE SLEEP DISORDER CENTER LLC
Entity Type:Organization
Organization Name:LOUISVILLE SLEEP DISORDER CENTER LLC
Other - Org Name:AMERICAN SLEEP MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-517-5500
Mailing Address - Street 1:7900 BELFORT PARKWAY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6978
Mailing Address - Country:US
Mailing Address - Phone:904-517-5500
Mailing Address - Fax:904-517-5501
Practice Address - Street 1:4010 DUPONT CIRCLE
Practice Address - Street 2:SUITE 122
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40017-4842
Practice Address - Country:US
Practice Address - Phone:502-899-9199
Practice Address - Fax:502-899-1617
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERICAN SLEEP MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-21
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY730067261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5005511OtherKY PASSPORT ID NUMBER
KYP00077209OtherMEDICARE RR ID NUMBER
KY65941007Medicaid
KY9369701Medicare ID - Type UnspecifiedMEDICARE ID NUMBER