Provider Demographics
NPI:1679539258
Name:UNIVERSITY OF LOUISVILLE RESEARCH FOUNDATION
Entity Type:Organization
Organization Name:UNIVERSITY OF LOUISVILLE RESEARCH FOUNDATION
Other - Org Name:UOFL FAMILY MEDICINE @ ACB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPARTMENT CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-852-8498
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:STE 290
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1785
Mailing Address - Country:US
Mailing Address - Phone:502-217-5134
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:550 S JACKSON ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1622
Practice Address - Country:US
Practice Address - Phone:502-562-6503
Practice Address - Fax:502-562-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100108960 (ARNPS)Medicaid
KY1120262OtherPASSPORT HEALTH PLAN
KY7100091550Medicaid
KY1120262OtherPASSPORT HEALTH PLAN