Basic Information
Provider Information | |||||||||
NPI: | 1992911960 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICAL THERAPY ASSOCIATES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 403 N MILES ST | ||||||||
Address2: |   | ||||||||
City: | ELIZABETHTOWN | ||||||||
State: | KY | ||||||||
PostalCode: | 427011834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2703609129 | ||||||||
FaxNumber: | 2702348197 | ||||||||
Practice Location | |||||||||
Address1: | 800 W LINCOLN TRAIL BLVD STE 7 | ||||||||
Address2: |   | ||||||||
City: | RADCLIFF | ||||||||
State: | KY | ||||||||
PostalCode: | 401602671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2703521061 | ||||||||
FaxNumber: | 2703521067 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2007 | ||||||||
LastUpdateDate: | 08/07/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COFFMAN | ||||||||
AuthorizedOfficialFirstName: | BRADLEY | ||||||||
AuthorizedOfficialMiddleName: | GORDON | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2703609129 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 002884 | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.