Provider Demographics
NPI:1508000951
Name:INDEPENDENCE URGENT CARE LLC
Entity Type:Organization
Organization Name:INDEPENDENCE URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BASHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIJAWI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-363-3330
Mailing Address - Street 1:2025 DECLARATION DRIVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051
Mailing Address - Country:US
Mailing Address - Phone:859-363-3330
Mailing Address - Fax:
Practice Address - Street 1:2025 DECLARATION DRIVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051
Practice Address - Country:US
Practice Address - Phone:859-363-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0726566261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100091380Medicaid
KY01080Medicare PIN