Provider Demographics
NPI:1477605772
Name:WALLACE, GUY ROBERT (PT)
Entity Type:Individual
Prefix:MR
First Name:GUY
Middle Name:ROBERT
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N MILES ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1834
Mailing Address - Country:US
Mailing Address - Phone:270-360-9129
Mailing Address - Fax:270-234-8197
Practice Address - Street 1:1222 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2710
Practice Address - Country:US
Practice Address - Phone:270-234-1569
Practice Address - Fax:270-234-0680
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002884225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000176410OtherBLUE CROSS
KY87000048Medicaid
KY2439083000OtherPASSPORT
KY000000176410OtherBLUE CROSS
KY2439083000OtherPASSPORT
KY5022902Medicare ID - Type Unspecified