Provider Demographics
NPI:1720299431
Name:ENGELHARDT, MICHELLE THERESA (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESA
Last Name:ENGELHARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:T
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1025 NEW MOODY LN
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9154
Practice Address - Country:US
Practice Address - Phone:502-222-8535
Practice Address - Fax:502-222-3932
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57011470207R00000X
KY42622207R00000X, 208M00000X
IL125053703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000652964OtherANTHEM
KY50026569OtherPASSPORT
KY7100094770Medicaid
KYP00938304Medicare PIN
KY7100094770Medicaid