Provider Demographics
NPI:1619202306
Name:OLD HENRY FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:OLD HENRY FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-295-8141
Mailing Address - Street 1:2503 BUSH RIDGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5885
Mailing Address - Country:US
Mailing Address - Phone:502-245-2701
Mailing Address - Fax:502-290-2839
Practice Address - Street 1:2503 BUSH RIDGE DR
Practice Address - Street 2:SUITE A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5885
Practice Address - Country:US
Practice Address - Phone:502-245-2701
Practice Address - Fax:502-290-2839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty