Provider Demographics
NPI:1649278938
Name:IMBURGIA, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:IMBURGIA
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 1:310 E BROADWAY STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1745
Mailing Address - Country:US
Mailing Address - Phone:502-245-0002
Mailing Address - Fax:502-742-0485
Practice Address - Street 1:310 E BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1745
Practice Address - Country:US
Practice Address - Phone:502-245-0002
Practice Address - Fax:502-742-0485
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26431207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64264310Medicaid
KY64264310Medicaid
D16657Medicare UPIN
KYP400033756Medicare PIN
KYK040700Medicare PIN