Provider Demographics
NPI:1861413098
Name:UNIVERSITY OF LOUISVILLE
Entity type:Organization
Organization Name:UNIVERSITY OF LOUISVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOC DEAN FOR CLINICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-852-0982
Mailing Address - Street 1:501 S PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1701
Mailing Address - Country:US
Mailing Address - Phone:502-852-5128
Mailing Address - Fax:502-852-7163
Practice Address - Street 1:501 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1701
Practice Address - Country:US
Practice Address - Phone:502-852-5096
Practice Address - Fax:502-852-1110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE UNIVERSITY OF LOUISVILLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-22
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1151798OtherPASSPORT HEALTH PLAN SUHD
KY61940102Medicaid
IN100001450AMedicaid
KY1049975OtherPASSPORT HEALTH PLAN FPP
KY1048739OtherPASSPORT HEALTH PLAN
IN100001450AMedicaid
KY0530Medicare PIN
IN100001450AMedicaid