Healthcare Provider Details

I. General information

NPI: 1184041212
Provider Name (Legal Business Name): AMANDA FARRIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA HODGES

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 S FLOYD ST SUITE 412
LOUISVILLE KY
40202-3818
US

IV. Provider business mailing address

231 E CHESTNUT ST
LOUISVILLE KY
40202-1821
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-8828
  • Fax: 502-629-6783
Mailing address:
  • Phone: 502-588-0982
  • Fax: 502-588-0987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number49864
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49864
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: