Provider Demographics
NPI:1780047456
Name:DISTLER, HUNTINGTON & BLAIR PSC
Entity type:Organization
Organization Name:DISTLER, HUNTINGTON & BLAIR PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-243-2280
Mailing Address - Street 1:6400 WESTWIND WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-6773
Mailing Address - Country:US
Mailing Address - Phone:502-243-2227
Mailing Address - Fax:502-243-2237
Practice Address - Street 1:4402 CHURCHMAN AVE
Practice Address - Street 2:STE 306
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-3101
Practice Address - Country:US
Practice Address - Phone:502-367-6137
Practice Address - Fax:502-367-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1994DT152W00000X
KY24245207W00000X
KY35792207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65917833Medicaid
KY65917833Medicaid
KY3822Medicare PIN