Provider Demographics
NPI:1417256710
Name:DYNAMIC MEDICAL AND REHAB PLLC
Entity Type:Organization
Organization Name:DYNAMIC MEDICAL AND REHAB PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LISNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-426-9200
Mailing Address - Street 1:3747 DIANN MARIE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241
Mailing Address - Country:US
Mailing Address - Phone:502-426-9200
Mailing Address - Fax:502-426-9259
Practice Address - Street 1:3747 DIANN MARIE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241
Practice Address - Country:US
Practice Address - Phone:502-426-9200
Practice Address - Fax:502-426-9259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-25
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111N00000X, 363A00000X
174400000X, 2084N0400X, 332B00000X, 363L00000X
KY25368332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100205820Medicaid
KY000000710768OtherANTHEM
KY7100206020Medicaid
KY7100210310Medicaid
KY7100234180Medicaid
KY7100210390Medicaid
KY7100206020Medicaid
KY7100234180Medicaid