Provider Demographics
NPI:1861499576
Name:SEVERTSON, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SEVERTSON
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 1:6420 DUTCHMANS PKWY
Mailing Address - Street 2:380
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3372
Mailing Address - Country:US
Mailing Address - Phone:502-894-8441
Mailing Address - Fax:502-894-4453
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:380
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-894-8441
Practice Address - Fax:502-894-4453
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34466207Y00000X, 207YX0901X
IN01049174207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000045447OtherANTHEM FACET NUMBER
KY040012436OtherRAIL ROAD MEDICARE
KY64344666Medicaid
IN200175990AMedicaid
KY000000045447OtherANTHEM FACET NUMBER
KY64344666Medicaid
IN200175990AMedicaid