Provider Demographics
NPI:1982686127
Name:LUSK, MICHAEL A (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:LUSK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:A
Other - Last Name:LUSK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2010 MAN O WAR DR
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:KY
Mailing Address - Zip Code:41169
Mailing Address - Country:US
Mailing Address - Phone:606-571-6207
Mailing Address - Fax:
Practice Address - Street 1:10098 BEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-9168
Practice Address - Country:US
Practice Address - Phone:740-259-5536
Practice Address - Fax:740-259-2531
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002408225100000X
KY004114225100000X
OHPT 009744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2296082Medicaid
KY7303032000Medicaid
WV7303032000Medicaid
KY650022114Medicare PIN
KY7303032000Medicaid
WVLU4283351Medicare UPIN
OH2296082Medicaid
WV4063052Medicare PIN
OHLU4063053Medicare PIN
KY5024405Medicare PIN