Provider Demographics
NPI:1356689079
Name:BOURBON PHYSICIAN PRACTICE LLC
Entity Type:Organization
Organization Name:BOURBON PHYSICIAN PRACTICE LLC
Other - Org Name:CARLISLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:107 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:KY
Mailing Address - Zip Code:40311-1150
Mailing Address - Country:US
Mailing Address - Phone:859-289-4124
Mailing Address - Fax:859-289-4126
Practice Address - Street 1:107 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:KY
Practice Address - Zip Code:40311-1150
Practice Address - Country:US
Practice Address - Phone:859-289-4124
Practice Address - Fax:859-289-4126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2022-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QR1300X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty