Provider Demographics
NPI:1285991414
Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCGOVERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-426-2221
Mailing Address - Street 1:1868 PLAUDIT PLACE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509
Mailing Address - Country:US
Mailing Address - Phone:859-264-0512
Mailing Address - Fax:
Practice Address - Street 1:1868 PLAUDIT PLACE
Practice Address - Street 2:SUITE B
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509
Practice Address - Country:US
Practice Address - Phone:859-264-0512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100159410Medicaid
KYP100027229Medicare UPIN