Provider Demographics
NPI:1437373917
Name:ROCKY FORK FAMILY PRACTICE, INC
Entity Type:Organization
Organization Name:ROCKY FORK FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:GAY
Authorized Official - Last Name:KARNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-840-0427
Mailing Address - Street 1:8062 OVERMAN RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-6389
Mailing Address - Country:US
Mailing Address - Phone:937-840-0427
Mailing Address - Fax:937-393-5327
Practice Address - Street 1:8062 OVERMAN RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-6389
Practice Address - Country:US
Practice Address - Phone:937-840-0427
Practice Address - Fax:937-393-5327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2056242Medicaid
OH=========OtherTIN
OH=========OtherTIN