Healthcare Provider Details

I. General information

NPI: 1043597073
Provider Name (Legal Business Name): SOUTH OLDHAM FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 W HIGHWAY 22
CRESTWOOD KY
40014-9305
US

IV. Provider business mailing address

6520 W HIGHWAY 22
CRESTWOOD KY
40014-9305
US

V. Phone/Fax

Practice location:
  • Phone: 502-241-8488
  • Fax: 502-241-7424
Mailing address:
  • Phone: 502-241-8488
  • Fax: 502-241-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34317
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34317
License Number StateKY

VIII. Authorized Official

Name: KAMLESH DAVE
Title or Position: OWNER
Credential: M.D.
Phone: 502-241-8488