Provider Demographics
NPI:1366577520
Name:WEST MARKET STREET CHIROPRACTORS
Entity type:Organization
Organization Name:WEST MARKET STREET CHIROPRACTORS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-775-6440
Mailing Address - Street 1:2306 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1537
Mailing Address - Country:US
Mailing Address - Phone:502-775-6440
Mailing Address - Fax:502-775-6985
Practice Address - Street 1:2306 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1537
Practice Address - Country:US
Practice Address - Phone:502-775-6440
Practice Address - Fax:502-775-6985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4519111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85002293Medicaid
KY1170493Medicaid
KY000000226876OtherANTHEM
KY2440664000Medicare ID - Type UnspecifiedPASSPORT ADVANTAGE ID #
KY85002293Medicaid