Provider Demographics
NPI:1619496395
Name:FAMILY WELLCARE CLINIC, PLLC
Entity Type:Organization
Organization Name:FAMILY WELLCARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:ANTONE
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-481-7113
Mailing Address - Street 1:805 BARDSTOWN RD STE 12
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40069-1515
Mailing Address - Country:US
Mailing Address - Phone:859-481-7113
Mailing Address - Fax:859-481-7114
Practice Address - Street 1:805 BARDSTOWN RD STE 12
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:KY
Practice Address - Zip Code:40069
Practice Address - Country:US
Practice Address - Phone:859-481-7113
Practice Address - Fax:859-481-7114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64065865Medicaid