Basic Information
| Provider Information | |||||||||
| NPI: | 1043267503 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY FAMILY PRACTICE ASSOC. PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY | ||||||||
| Address2: | STE 290 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022175134 | ||||||||
| FaxNumber: | 5022175137 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 S JACKSON ST | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025626503 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEPARTMENT CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 5028528498 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65905960 | 05 | KY | MEDICAID |