1063563666 NPI number — COMMONWEALTH REHABILITATION & SPORTS MEDICINE, 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 1063563666 NPI number — COMMONWEALTH REHABILITATION & SPORTS MEDICINE, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH REHABILITATION & SPORTS MEDICINE, 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:
1063563666
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 911148
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40591-1148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-278-2121
Provider Business Mailing Address Fax Number:
859-276-1649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5874 VETERANS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41005-8824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-334-4331
Provider Business Practice Location Address Fax Number:
859-586-1798
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCRAY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
859-278-2121

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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