Provider Demographics
NPI:1225030224
Name:EDWIN CARMOUCHE MD PLLC
Entity Type:Organization
Organization Name:EDWIN CARMOUCHE MD PLLC
Other - Org Name:EDWIN CARMOUCHE
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:CARMOUCHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-895-7697
Mailing Address - Street 1:152 CHENOWETH LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2651
Mailing Address - Country:US
Mailing Address - Phone:502-895-7697
Mailing Address - Fax:502-895-7698
Practice Address - Street 1:152 CHENOWETH LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2651
Practice Address - Country:US
Practice Address - Phone:502-895-7697
Practice Address - Fax:502-895-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26724207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64267248Medicaid
IN201083940AMedicaid
KY7845Medicare PIN