Provider Demographics
NPI:1922337617
Name:LOUISVILLE GERIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:LOUISVILLE GERIATRIC ASSOCIATES
Other - Org Name:WALL STREET MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:I
Authorized Official - Last Name:MASROOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-288-8360
Mailing Address - Street 1:443 SPRING ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-4494
Mailing Address - Country:US
Mailing Address - Phone:812-288-8360
Mailing Address - Fax:812-288-8375
Practice Address - Street 1:443 SPRING ST STE 200
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4494
Practice Address - Country:US
Practice Address - Phone:812-288-8360
Practice Address - Fax:812-288-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-09
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300025251Medicaid
IN257640Medicare PIN
IN200920250BMedicaid