Provider Demographics
NPI:1619473006
Name:KOHLES FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:KOHLES FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOHLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-393-1488
Mailing Address - Street 1:1815 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-3164
Mailing Address - Country:US
Mailing Address - Phone:765-393-1488
Mailing Address - Fax:765-400-5217
Practice Address - Street 1:1815 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-3164
Practice Address - Country:US
Practice Address - Phone:765-393-1488
Practice Address - Fax:765-400-5217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300017273Medicaid