Provider Demographics
NPI:1922142983
Name:SOUTH OLDHAM MEDICAL CLINIC PSC
Entity Type:Organization
Organization Name:SOUTH OLDHAM MEDICAL CLINIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHOR
Authorized Official - Middle Name:
Authorized Official - Last Name:ALUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-241-8488
Mailing Address - Street 1:6520 W HWY 22
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014
Mailing Address - Country:US
Mailing Address - Phone:502-241-8488
Mailing Address - Fax:502-241-7424
Practice Address - Street 1:6520 W HWY 22
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014
Practice Address - Country:US
Practice Address - Phone:502-241-8488
Practice Address - Fax:502-241-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30373208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64303738Medicaid
0955001Medicare ID - Type Unspecified
KY64303738Medicaid