Provider Demographics
NPI:1295714251
Name:SENIOR, DALE (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:SENIOR
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:
Practice Address - Street 1:9880 ANGIES WAY
Practice Address - Street 2:STE. 410
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2851
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:502-891-8668
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27888207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64278880Medicaid
KYK142880Medicare PIN
KY64278880Medicaid
KYP00391798Medicare PIN
KY00546137Medicare Oscar/Certification