Basic Information
| Provider Information | |||||||||
| NPI: | 1982681169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAUREL | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5129 DIXIE HWY | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402161727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024478786 | ||||||||
| FaxNumber: | 5024478623 | ||||||||
| Practice Location | |||||||||
| Address1: | 5129 DIXIE HWY | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402161727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024478786 | ||||||||
| FaxNumber: | 5024478623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 34935 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200214890 | 05 | IN | MEDICAID | 64001415 | 05 | KY | MEDICAID |