Healthcare Provider Details

I. General information

NPI: 1013192376
Provider Name (Legal Business Name): INDEPENDENCE FAMILY PRACTICE P S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 MADISON PIKE STE 100
INDEPENDENCE KY
41051
US

IV. Provider business mailing address

5290 MADISON PIKE STE 100
INDEPENDENCE KY
41051
US

V. Phone/Fax

Practice location:
  • Phone: 859-363-8600
  • Fax: 859-960-0003
Mailing address:
  • Phone: 859-363-8600
  • Fax: 859-960-0003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22978
License Number StateKY

VIII. Authorized Official

Name: JOHN FRANKLIN ALLNUTT
Title or Position: PRESIDENT
Credential: MD
Phone: 859-363-8600