Provider Demographics
NPI:1063661445
Name:MACKELAITE, LINA (MD)
Entity type:Individual
Prefix:DR
First Name:LINA
Middle Name:
Last Name:MACKELAITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-852-5757
Mailing Address - Fax:502-852-7643
Practice Address - Street 1:615 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1715
Practice Address - Country:US
Practice Address - Phone:502-852-5757
Practice Address - Fax:502-589-5093
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT183311207R00000X
KY43697207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100134410Medicaid