1811148547 NPI number — REHAB ON THE ROAD, PSC

Table of content: (NPI 1811148547)

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".




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