Provider Demographics
NPI:1790975670
Name:LOUISVILLE EMERGENCY MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:LOUISVILLE EMERGENCY MEDICINE ASSOCIATES
Other - Org Name:LOUISVILLE EMERGENCY MEDICINE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:GERUGHTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-899-7646
Mailing Address - Street 1:PO BOX 6749
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0749
Mailing Address - Country:US
Mailing Address - Phone:502-899-7716
Mailing Address - Fax:502-899-7648
Practice Address - Street 1:4000 KRESGE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4605
Practice Address - Country:US
Practice Address - Phone:502-897-8141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78905155Medicaid