1164614368 NPI number — IROQUOIS MEDICAL CENTER,P.S.C.

Table of content: (NPI 1164614368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164614368 NPI number — IROQUOIS MEDICAL CENTER,P.S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IROQUOIS MEDICAL CENTER,P.S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
IMC FAMILY MEDICINE
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164614368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5601 S 3RD ST
Provider Second Line Business Mailing Address:
100
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40214-2615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-366-7720
Provider Business Mailing Address Fax Number:
502-366-0824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 W HEBRON LN
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SHEPHERDSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40165-7465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-957-7580
Provider Business Practice Location Address Fax Number:
502-957-6667
Provider Enumeration Date:
08/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
NEVA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
502-366-7720

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34540 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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