Provider Demographics
NPI:1003807819
Name:BROOKS, MARK E (PT, DSC, ECS, OCS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PT, DSC, ECS, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5027 ATWOOD DR STE 2B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8322
Mailing Address - Country:US
Mailing Address - Phone:859-625-0001
Mailing Address - Fax:859-625-1109
Practice Address - Street 1:116 MERIDIAN WAY STE 9
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2876
Practice Address - Country:US
Practice Address - Phone:859-626-3131
Practice Address - Fax:859-625-1109
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT38134225100000X
KY001746225100000X, 2251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000215122OtherBC/BS SPTA
KY000000310944OtherBC/BS RPTA
KY000000060027OtherBC/BS LPTA
KY000000333709OtherBC/BS HPTA
KY611208897OtherBLUEGRASS FAMILY
KY611208897OtherHUMANA
KY611208897OtherWORKERS COMP.
KY87000006Medicaid
KY611208897OtherAETNA
KY611208897OtherTRICARE
KY87000006Medicaid
KY5030103Medicare ID - Type UnspecifiedHARRISON CLINIC
KY611208897OtherAETNA
KY000000060027OtherBC/BS LPTA