Provider Demographics
NPI:1922211556
Name:PENDLETON, MICHAEL ELI (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ELI
Last Name:PENDLETON
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 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:215 CENTRAL AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208
Practice Address - Country:US
Practice Address - Phone:502-588-8720
Practice Address - Fax:502-588-8721
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50029699OtherPASSPORT HEALTH PLAN
KY50029700OtherPASSPORT HEALTH PLAN
KY50029698OtherPASSPORT HEALTH PLAN
KY7100127990Medicaid
KY50029701OtherPASSPORT HEALTH PLAN
KY7100127990Medicaid
KYP400024240Medicare PIN
KYP400024232Medicare PIN
KYP400024237Medicare PIN