Provider Demographics
NPI:1043597073
Name:SOUTH OLDHAM FAMILY CARE
Entity Type:Organization
Organization Name:SOUTH OLDHAM FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAMLESH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-241-8488
Mailing Address - Street 1:6520 W HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-9305
Mailing Address - Country:US
Mailing Address - Phone:502-241-8488
Mailing Address - Fax:502-241-7424
Practice Address - Street 1:6520 W HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9305
Practice Address - Country:US
Practice Address - Phone:502-241-8488
Practice Address - Fax:502-241-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34317207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty