Basic Information
| Provider Information | |||||||||
| NPI: | 1588640189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC TRAUMA ASSOCIATES, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 E GRAY ST | ||||||||
| Address2: | SUITE 564 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295460 | ||||||||
| FaxNumber: | 5026295461 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 E GRAY ST | ||||||||
| Address2: | SUITE 564 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295460 | ||||||||
| FaxNumber: | 5026295461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | RUTLEDGE | ||||||||
| AuthorizedOfficialFirstName: | CAROLE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5026295460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 64227460 | 05 | KY | MEDICAID | 64225279 | 05 | KY | MEDICAID |