Provider Demographics
NPI:1326357930
Name:SOUTHALL, ADAM J (DPT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:J
Last Name:SOUTHALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 ZANDALE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2644
Mailing Address - Country:US
Mailing Address - Phone:270-576-5770
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:2700 STANLEY GAULT PKWY
Practice Address - Street 2:STE 129
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5176
Practice Address - Country:US
Practice Address - Phone:859-263-0595
Practice Address - Fax:859-263-0385
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT005686225100000X
OHPT013083225100000X
WVPT002931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810019746Medicaid
OH3083676Medicaid
WV3810019746Medicaid
OH3083676Medicaid
WV4304472Medicare PIN