Provider Demographics
NPI:1386070019
Name:SUSAN RAGHAVAN, MD
Entity type:Organization
Organization Name:SUSAN RAGHAVAN, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPT
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINSTERKETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-327-9703
Mailing Address - Street 1:9720 PARK PLAZA AVE UNIT 202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2290
Mailing Address - Country:US
Mailing Address - Phone:502-327-9703
Mailing Address - Fax:502-327-9798
Practice Address - Street 1:9720 PARK PLAZA AVE UNIT 202
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2290
Practice Address - Country:US
Practice Address - Phone:502-327-9703
Practice Address - Fax:502-327-9798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY345552080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2080P0205XOtherPEDIATRIC ENDOCRINOLOGY
KY64880008Medicaid