Provider Demographics
NPI:1962686261
Name:KERRY L SHORT, M.D.
Entity Type:Organization
Organization Name:KERRY L SHORT, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SHORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-897-7416
Mailing Address - Street 1:4001 KRESGE WAY STE 315
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4640
Mailing Address - Country:US
Mailing Address - Phone:502-897-7416
Mailing Address - Fax:502-895-6638
Practice Address - Street 1:4001 KRESGE WAY STE 315
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4640
Practice Address - Country:US
Practice Address - Phone:502-897-7416
Practice Address - Fax:502-895-6638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20965208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64209653Medicaid
KY64209653Medicaid
KYC71584Medicare UPIN