1144693631 NPI number — MICHAEL ANTHONY KIDWELL PT, DPT

Table of content: MICHAEL ANTHONY KIDWELL PT, DPT (NPI 1144693631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144693631 NPI number — MICHAEL ANTHONY KIDWELL PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIDWELL
Provider First Name:
MICHAEL
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
M

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:
1144693631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
708 WESTPORT RD
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42701-3819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-766-1213
Provider Business Mailing Address Fax Number:
270-766-1115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 WESTPORT RD
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-3819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-766-1213
Provider Business Practice Location Address Fax Number:
270-766-1115
Provider Enumeration Date:
11/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  006742 , 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)





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