Provider Demographics
NPI:1770575516
Name:LOUISVILLE SURGICAL ASSOCIATES, PSC
Entity type:Organization
Organization Name:LOUISVILLE SURGICAL ASSOCIATES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-366-1090
Mailing Address - Street 1:4402 CHURCHMAN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1190
Mailing Address - Country:US
Mailing Address - Phone:502-366-1090
Mailing Address - Fax:502-366-1564
Practice Address - Street 1:4402 CHURCHMAN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1190
Practice Address - Country:US
Practice Address - Phone:502-366-1090
Practice Address - Fax:502-366-1564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000060149OtherANTHEM
KY65920985Medicaid
KYCN1016OtherRAILROAD MEDICARE
KY1049011OtherPASSPORT
KY2586Medicare ID - Type Unspecified