Provider Demographics
NPI:1275549842
Name:INTERVENTIONAL REHABILITATION OF KENTUCKY, P.S.C
Entity Type:Organization
Organization Name:INTERVENTIONAL REHABILITATION OF KENTUCKY, P.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:COLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-589-4765
Mailing Address - Street 1:315 E BROADWAY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3700
Mailing Address - Country:US
Mailing Address - Phone:502-589-4765
Mailing Address - Fax:502-589-4799
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:SUITE 250
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-589-4765
Practice Address - Fax:502-589-4799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200279470AMedicaid
KY1103005Medicaid
2322033OtherAETNA
KY65943870Medicaid
372286700OtherOWCP
372286700OtherOWCP
KY6215Medicare PIN
KY1103005Medicaid
CJ8680Medicare PIN