Provider Demographics
NPI:1518073105
Name:EAST SIDE FAMILY MEDICINE, PSC
Entity Type:Organization
Organization Name:EAST SIDE FAMILY MEDICINE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:COURTNEY
Authorized Official - Last Name:HADDIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-695-3946
Mailing Address - Street 1:601 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-3857
Mailing Address - Country:US
Mailing Address - Phone:502-695-3946
Mailing Address - Fax:502-695-3847
Practice Address - Street 1:601 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-3857
Practice Address - Country:US
Practice Address - Phone:502-695-3946
Practice Address - Fax:502-695-3847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6270Medicare ID - Type Unspecified