Basic Information
| Provider Information | |||||||||
| NPI: | 1508845868 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOCINCY ORTHOPAEDICS & SPORTS MEDICINE | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMONWEALTH ORTHOPAEDIC CENTERS PSC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135574270 | ||||||||
| FaxNumber: | 5135573214 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 SOUTH LOOP ROAD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593010700 | ||||||||
| FaxNumber: | 8593010655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REIS | ||||||||
| AuthorizedOfficialFirstName: | JOANN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8598177070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHOCINCY | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 65942401 | 05 | KY | MEDICAID | 8790057700 | 05 | KY | MEDICAID |