Provider Demographics
NPI:1922014794
Name:PEVELER, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:PEVELER
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 1:610 AUDUBON MEDICAL PLAZA
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217
Mailing Address - Country:US
Mailing Address - Phone:502-635-7455
Mailing Address - Fax:502-634-9296
Practice Address - Street 1:610 AUDUBON MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-635-7455
Practice Address - Fax:502-634-9296
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13934208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
C73306Medicare UPIN
FLCQ105ZMedicare UPIN
1272901Medicare ID - Type Unspecified