Provider Demographics
NPI:1508936261
Name:LOUISVILLE CARDIOLOGY MEDICAL GROUP, PSC
Entity Type:Organization
Organization Name:LOUISVILLE CARDIOLOGY MEDICAL GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:F
Authorized Official - Last Name:LICANDRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-893-7710
Mailing Address - Street 1:3900 KRESGE WAY
Mailing Address - Street 2:SUITE 60
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4660
Mailing Address - Country:US
Mailing Address - Phone:502-893-7710
Mailing Address - Fax:502-893-1391
Practice Address - Street 1:3900 KRESGE WAY
Practice Address - Street 2:SUITE 60
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4660
Practice Address - Country:US
Practice Address - Phone:502-893-7710
Practice Address - Fax:502-893-1391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65929820Medicaid
KY65929820Medicaid