Provider Demographics
NPI:1376547711
Name:COHEN, IRWIN RANDELL
Entity type:Individual
Prefix:
First Name:IRWIN
Middle Name:RANDELL
Last Name:COHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4307 GLENARM RD
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-9586
Mailing Address - Country:US
Mailing Address - Phone:502-241-2892
Mailing Address - Fax:
Practice Address - Street 1:4006 DUTCHMANS LN
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4704
Practice Address - Country:US
Practice Address - Phone:502-873-7517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY299082085R0202X, 207RA0401X
MO20110007342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64299084Medicaid
IN200165860Medicaid
KY0636109Medicare ID - Type Unspecified
KY64299084Medicaid
KYG22182Medicare UPIN
MO152360418Medicare PIN