Healthcare Provider Details

I. General information

NPI: 1356018519
Provider Name (Legal Business Name): LOUISVILLE OBSERVATIONAL MEDICINE ASSOCIATES PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 KRESGE WAY
LOUISVILLE KY
40207-4605
US

IV. Provider business mailing address

PO BOX 778730
CHICAGO IL
60677-8730
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-8100
  • Fax: 904-265-8181
Mailing address:
  • Phone: 502-215-4229
  • Fax: 904-265-8181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM D HOLLAND
Title or Position: PRESIDENT
Credential: MD
Phone: 502-897-8100