Provider Demographics
NPI:1912188541
Name:UNIVERSITY OF LOUISVILLE
Entity Type:Organization
Organization Name:UNIVERSITY OF LOUISVILLE
Other - Org Name:ORAL PATHOLOGY LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:502-852-5128
Mailing Address - Street 1:501 SOUTH PRESTON STREET
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40292-0001
Mailing Address - Country:US
Mailing Address - Phone:502-852-5103
Mailing Address - Fax:502-852-5593
Practice Address - Street 1:501 SOUTH PRESTON STREET
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40292-0001
Practice Address - Country:US
Practice Address - Phone:502-852-5103
Practice Address - Fax:502-852-5593
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF LOUISVILLE SCHOOL OF DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-26
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18D0648475291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4013501Medicare PIN
KYW01743Medicare UPIN