Healthcare Provider Details

I. General information

NPI: 1518073105
Provider Name (Legal Business Name): EAST SIDE FAMILY MEDICINE, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 VERSAILLES RD
FRANKFORT KY
40601-3857
US

IV. Provider business mailing address

601 VERSAILLES RD
FRANKFORT KY
40601-3857
US

V. Phone/Fax

Practice location:
  • Phone: 502-695-3946
  • Fax: 502-695-3847
Mailing address:
  • Phone: 502-695-3946
  • Fax: 502-695-3847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ALLEN COURTNEY HADDIX
Title or Position: PRESIDENT
Credential: M.D
Phone: 502-695-3946