Provider Demographics
NPI:1942230578
Name:A BERT SPARROW PSC
Entity type:Organization
Organization Name:A BERT SPARROW PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ATHEL
Authorized Official - Middle Name:BERT
Authorized Official - Last Name:SPARROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-361-6075
Mailing Address - Street 1:4402 CHURCHMAN AVE
Mailing Address - Street 2:STE 211
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-3100
Mailing Address - Country:US
Mailing Address - Phone:502-361-6075
Mailing Address - Fax:502-361-6071
Practice Address - Street 1:4402 CHURCHMAN AVE
Practice Address - Street 2:STE 211
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-3100
Practice Address - Country:US
Practice Address - Phone:502-361-6075
Practice Address - Fax:502-361-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13980208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY022087143OtherRAILROAD MEDICARE
KY1048991OtherPASSPORT
000000045552OtherBLUE CROSS BLUE SHIELD
KY65934580Medicaid
IN100003430 AMedicaid
KY2432327000OtherPASSPORT ADVANTAGE
KY1079501Medicare PIN