Provider Demographics
NPI:1255638938
Name:JAMES T DODGE DO LLC
Entity type:Organization
Organization Name:JAMES T DODGE DO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-955-1412
Mailing Address - Street 1:1905 W HEBRON LN STE 205
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-7467
Mailing Address - Country:US
Mailing Address - Phone:877-349-1411
Mailing Address - Fax:502-349-0980
Practice Address - Street 1:1905 W HEBRON LN STE 205
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-7467
Practice Address - Country:US
Practice Address - Phone:877-349-1411
Practice Address - Fax:502-349-0980
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JAMES T DODGE DO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-16
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006404367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty