Provider Demographics
NPI:1780682609
Name:FAMILY & INTERNAL MEDICINE ASSOCIATES PLLC
Entity Type:Organization
Organization Name:FAMILY & INTERNAL MEDICINE ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:OSBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-699-9500
Mailing Address - Street 1:325 W WALNUT ST
Mailing Address - Street 2:STE 600
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1378
Mailing Address - Country:US
Mailing Address - Phone:270-699-9500
Mailing Address - Fax:270-699-9550
Practice Address - Street 1:325 W WALNUT ST
Practice Address - Street 2:STE 600
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1378
Practice Address - Country:US
Practice Address - Phone:270-699-9500
Practice Address - Fax:270-699-9550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65932105Medicaid
KY1077750OtherPASSPORT
KY2435329002OtherPASSPORT ADVANTAGE
KY18D0320437OtherCLIA
KY35002005Medicaid
KY2435329002OtherPASSPORT ADVANTAGE