Basic Information
Provider Information | |||||||||
NPI: | 1396156972 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOCINCY ORTHOPAEDICS & SPORTS MEDICINE PSC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 560 S LOOP RD | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | KY | ||||||||
PostalCode: | 410173405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593012663 | ||||||||
FaxNumber: | 8593010655 | ||||||||
Practice Location | |||||||||
Address1: | 8726 US 42 | ||||||||
Address2: |   | ||||||||
City: | FLORENCE | ||||||||
State: | KY | ||||||||
PostalCode: | 41042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593012663 | ||||||||
FaxNumber: | 8593010655 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2014 | ||||||||
LastUpdateDate: | 08/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REIS | ||||||||
AuthorizedOfficialFirstName: | JOANN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8598177070 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CEO | ||||||||
NPICertificationDate: | 08/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207R00000X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RM1200X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Magnetic Resonance Imaging (MRI) | 207XS0106X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 213E00000X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   | 225100000X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 332B00000X |   | KY | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 363AM0700X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X |   | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207X00000X |   | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 9590071800 | 01 | KY | MEDICAID PHYSICIAN ASSISTANT | OTHER | 7100185740 | 01 | KY | MEDICAID NURSE PRACTITIONER | OTHER | 7100147130 | 01 | KY | MEDICAID PHYSICAL THERAPIST | OTHER | 90008962 | 01 | KY | MEDICAID DME | OTHER | 65927881 GROUP | 05 | KY |   | MEDICAID | 80900186 | 01 | KY | MEDICAID PODIATRIST | OTHER |