Basic Information
| Provider Information | |||||||||
| NPI: | 1578528246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOX | ||||||||
| FirstName: | LOUISE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGAVIC | ||||||||
| OtherFirstName: | LOUISE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 12615 TAYLORSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402994452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022611595 | ||||||||
| FaxNumber: | 5022611599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 11/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 29848 | KY | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 000014952X | 01 | HUMANA / NCMA | OTHER | 2446866000 | 01 | KY | PASSPORT ADVANTAGE - NCMA | OTHER | 50005562 | 01 | KY | PASSPORT - NCMA | OTHER | 50025010 | 01 | PASSPORT / NCMA TYLER | OTHER | 7398219 | 01 | CIGNA / NCMA | OTHER | P00219045 | 01 | KY | RAILROAD MEDICARE | OTHER | 048233 | 01 | SIHO / NCMA | OTHER | 2446866000 | 01 | PASSPORT ADVANTAGE / NCMA -TYLER | OTHER | 64298482 | 05 | KY | MEDICAID | 1194518 | 01 | CHA / NCMA | OTHER | 0000350819 | 01 | KY | ANTHEM - NCMA | OTHER | 3729659000 | 01 | KY | PASSPORT ADVANGATE - TYLER | OTHER |