1588866875 NPI number — DR. SHAWN CROSS PT

Table of content: DR. SHAWN CROSS PT (NPI 1588866875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588866875 NPI number — DR. SHAWN CROSS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROSS
Provider First Name:
SHAWN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1588866875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1925 BLANKENBAKER PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40299-2403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-267-4851
Provider Business Mailing Address Fax Number:
502-267-4852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1925 BLANKENBAKER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40299-2403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-267-4851
Provider Business Practice Location Address Fax Number:
502-267-4852
Provider Enumeration Date:
05/31/2007

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:  005085 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 0012079 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 005085 . This is a "KY STATE BOARD OF PT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".