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General NPI Number Information
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NPI Number | 1902227937
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH FAMILY MEDICINE PLLC
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Dates
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Enumeration Date | 12/17/2013
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Last Update Date | 08/03/2017
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Provider Practice Location Address
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Address Line | 12400 SHELBYVILLE RD
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City | LOUISVILLE
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State | KY
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Zip | 40243-1419
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Country | US
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Telephone | 502-883-2218
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Fax |
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Provider Business Mailing Address
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Address Line | 12400 SHELBYVILLE ROAD
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City | LOUISVILLE
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State | KY
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Zip | 40245-4313
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Country | US
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Telephone | 502-883-2218
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | RAY CHARLES KENNEDY
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Credential | MD
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Telephone | 502-377-8138
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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