Provider Demographics
NPI:1760566392
Name:JEWISH HOSPITAL FPA
Entity Type:Organization
Organization Name:JEWISH HOSPITAL FPA
Other - Org Name:JEWISH HOSPITAL FPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIRENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-654-0889
Mailing Address - Street 1:7612 SHEPHERDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-2963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7612 SHEPHERDSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-2963
Practice Address - Country:US
Practice Address - Phone:502-968-6226
Practice Address - Fax:502-966-5562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18030332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1826796OtherOTHER ID NUMBER-COMMERCIAL NUMBER
KY64480300Medicaid
C73640Medicare ID - Type Unspecified