1811148547 NPI number — REHAB ON THE ROAD, PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811148547 NPI number — REHAB ON THE ROAD, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REHAB ON THE ROAD, PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811148547
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 MAN O WAR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNION
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41091-8067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-645-1053
Provider Business Mailing Address Fax Number:
888-390-7623

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MAN O WAR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNION
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41091-8067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-645-1053
Provider Business Practice Location Address Fax Number:
888-390-7623
Provider Enumeration Date:
09/30/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOOK
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
ALLAN
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
502-645-1053

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  31321 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000074661 . This is a "ANTHEM PROVIDER #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200179480A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1102772 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2436318000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64-313216 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00003391 . This is a "RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1285608752 . This is a "NPI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 250010583 . This is a "RAILROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".