Provider Demographics
NPI:1780785964
Name:TOMMY L. LOUISVILLE, M.D., PA
Entity type:Organization
Organization Name:TOMMY L. LOUISVILLE, M.D., PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LOUISVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-299-8485
Mailing Address - Street 1:320 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3501
Mailing Address - Country:US
Mailing Address - Phone:863-299-8485
Mailing Address - Fax:863-293-8450
Practice Address - Street 1:320 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3501
Practice Address - Country:US
Practice Address - Phone:863-299-8485
Practice Address - Fax:863-293-8450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4663Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER