Provider Demographics
NPI:1164614368
Name:IROQUOIS MEDICAL CENTER,P.S.C.
Entity Type:Organization
Organization Name:IROQUOIS MEDICAL CENTER,P.S.C.
Other - Org Name:IMC FAMILY MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:NEVA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-366-7720
Mailing Address - Street 1:5601 S 3RD ST
Mailing Address - Street 2:100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-2615
Mailing Address - Country:US
Mailing Address - Phone:502-366-7720
Mailing Address - Fax:502-366-0824
Practice Address - Street 1:1905 W HEBRON LN
Practice Address - Street 2:SUITE 103
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-7465
Practice Address - Country:US
Practice Address - Phone:502-957-7580
Practice Address - Fax:502-957-6667
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IROQUOIS MEDICAL CENTER, P.S.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-13
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty