Provider Demographics
NPI:1710102629
Name:MARK O GLADSTEIN MD PLLC
Entity Type:Organization
Organization Name:MARK O GLADSTEIN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:O
Authorized Official - Last Name:GLADSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-589-4448
Mailing Address - Street 1:250 E LIBERTY ST
Mailing Address - Street 2:SUITE 1005
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1538
Mailing Address - Country:US
Mailing Address - Phone:502-589-4448
Mailing Address - Fax:502-589-1209
Practice Address - Street 1:250 E LIBERTY ST
Practice Address - Street 2:SUITE 1005
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1538
Practice Address - Country:US
Practice Address - Phone:502-589-4448
Practice Address - Fax:502-589-1209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
20041432OtherRR MEDICARE
KY50009936Medicaid
KY64144546Medicaid
KY9001304600Medicaid
KY1059292Medicaid
KY4290790001Medicare NSC
KY1897701Medicare PIN
KY1577001Medicare ID - Type Unspecified
KYC73675Medicare UPIN