Healthcare Provider Details

I. General information

NPI: 1043497167
Provider Name (Legal Business Name): JAMES T DODGE DO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 CHAMBERS BLVD STE B
BARDSTOWN KY
40004-2574
US

IV. Provider business mailing address

919 CHAMBERS BLVD STE B
BARDSTOWN KY
40004-2574
US

V. Phone/Fax

Practice location:
  • Phone: 502-349-1411
  • Fax: 502-349-0980
Mailing address:
  • Phone: 502-349-1411
  • Fax: 502-349-0980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02609
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number02609
License Number StateKY

VIII. Authorized Official

Name: DR. JAMES T. DODGE
Title or Position: OWNER
Credential: D.O.
Phone: 502-349-1411