MEDICARE: OLD HENRY FAMILY PRACTICE, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1619202306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD HENRY FAMILY PRACTICE, PLLC

Provider Business Mailing Address
First Line	:	2503 BUSH RIDGE DR
Second Line	:	SUITE A
City	:	LOUISVILLE
State	:	KY
Zip	:	40245-5885
Country	:	US
Telephone Number	:	502-245-2701
Fax Number	:	502-290-2839

Provider Business Practice Location Address
First Line	:	2503 BUSH RIDGE DR
Second Line	:	SUITE A
City	:	LOUISVILLE
State	:	KY
Zip	:	40245-5885
Country	:	US
Telephone Number	:	502-245-2701
Fax Number	:	502-290-2839

Authorized Official
Title or Position	:	OWNER
Name	:	RICHA GUPTA
Credential	:	MD
Telephone Number	:	502-295-8141

Provider Enumeration Date	:	10/14/2009
Last Update Date	:	09/29/2011

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