Provider Demographics
NPI:1184663015
Name:LOUISVILLE FAMILY & SPORTS MEDICINE PSC
Entity type:Organization
Organization Name:LOUISVILLE FAMILY & SPORTS MEDICINE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:V
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-426-4264
Mailing Address - Street 1:9420 BROWNSBORO RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1118
Mailing Address - Country:US
Mailing Address - Phone:502-426-4264
Mailing Address - Fax:502-426-4221
Practice Address - Street 1:9420 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-1118
Practice Address - Country:US
Practice Address - Phone:502-426-4264
Practice Address - Fax:402-426-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000346469OtherANTHM BCBS-ST
KY6593237800Medicaid
KY000000052204OtherANTHEM BCBS-CP
KY000000052203OtherANTHEM BCBS-GP
KY000000052203OtherANTHEM BCBS-GP