Provider Demographics
NPI:1659483311
Name:SPAIN, JEFF A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:A
Last Name:SPAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36218
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40233-6218
Mailing Address - Country:US
Mailing Address - Phone:502-634-6767
Mailing Address - Fax:502-634-6775
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-634-6767
Practice Address - Fax:502-634-6775
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31257207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000786114OtherANTHEM BC/BS
KY31257OtherKY LICENSE
KY50042931OtherPASSPORT
KY64312572Medicaid
IN200159040Medicaid
0611509Medicare ID - Type Unspecified
G50451Medicare UPIN
KY64312572Medicaid