Basic Information
| Provider Information | |||||||||
| NPI: | 1689831158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DO NOT USE | ||||||||
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| OtherOrganizationName: | BAPTISTWORX | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 STANLEY GAULT PKWY STE 201 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022531035 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11630 COMMONWEALTH DR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402992300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022676292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 08/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | FRUM | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5022382801 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST COMMUNITY HEALTH SERVICES, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 9536 | 01 | KY | MEDICARE GROUP | OTHER |