Provider Demographics
NPI:1346305430
Name:SPECIALTY ORTHOPAEDICS PSC
Entity Type:Organization
Organization Name:SPECIALTY ORTHOPAEDICS PSC
Other - Org Name:KENTUCKIANA FOOT & ANKLE SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-721-8288
Mailing Address - Street 1:6400 DUTCHMANS PKWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3340
Mailing Address - Country:US
Mailing Address - Phone:502-721-8288
Mailing Address - Fax:502-721-8792
Practice Address - Street 1:6400 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 215
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3340
Practice Address - Country:US
Practice Address - Phone:502-721-8288
Practice Address - Fax:502-721-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00251213ES0103X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80900293OtherGRP PODIATRY MEDICAID