Provider Demographics
NPI:1265406987
Name:SHRADER, ROBB R (MD)
Entity type:Individual
Prefix:DR
First Name:ROBB
Middle Name:R
Last Name:SHRADER
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 1:3810 SPRINGHURST BLVD # 100
Mailing Address - Street 2:MERIDIAN BUILDING
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-6100
Mailing Address - Country:US
Mailing Address - Phone:502-897-9881
Mailing Address - Fax:
Practice Address - Street 1:3810 SPRINGHURST BLVD # 100
Practice Address - Street 2:MERIDIAN BUILDING
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6100
Practice Address - Country:US
Practice Address - Phone:502-897-9881
Practice Address - Fax:502-897-9824
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26845174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY26845OtherLICENSE NUMBER
KY6426845100Medicaid
KY6426845100Medicaid
E10501Medicare UPIN