Basic Information
Provider Information | |||||||||
NPI: | 1639644560 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOCINCY ORTHOPAEDICS & SPORTS MEDICINE PSC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
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OtherMiddleName: |   | ||||||||
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OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 560 S LOOP RD | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | KY | ||||||||
PostalCode: | 410173405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593012663 | ||||||||
FaxNumber: | 8598177848 | ||||||||
Practice Location | |||||||||
Address1: | 605 WILSON CREEK RD | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEBURG | ||||||||
State: | IN | ||||||||
PostalCode: | 470252506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593012663 | ||||||||
FaxNumber: | 8598177848 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2018 | ||||||||
LastUpdateDate: | 08/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REIS | ||||||||
AuthorizedOfficialFirstName: | JOANN | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8593012663 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
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NPICertificationDate: | 08/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RS0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 207XS0106X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0114X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XX0005X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 2081S0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 213E00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.