Provider Demographics
| NPI: | 1598714560 |
|---|---|
| Name: | ORTHOCINCY ORTHOPAEDICS & SPORTS MEDICINE PSC |
| Entity Type: | Organization |
| Organization Name: | ORTHOCINCY ORTHOPAEDICS & SPORTS MEDICINE PSC |
| Other - Org Name: | ORTHOCINCY ORTHOPAEDICS & SPORTS MEDICINE |
| Other - Org Type: | Other Name |
| Authorized Official - Title/Position: | EXECUTIVE OFFICER/MANAGER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JOANN |
| Authorized Official - Middle Name: | M |
| Authorized Official - Last Name: | REIS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | CEO |
| Authorized Official - Phone: | 859-817-7070 |
| Mailing Address - Street 1: | 560 S LOOP RD |
| Mailing Address - Street 2: | |
| Mailing Address - City: | EDGEWOOD |
| Mailing Address - State: | KY |
| Mailing Address - Zip Code: | 41017-3405 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 859-301-2663 |
| Mailing Address - Fax: | 859-301-0655 |
| Practice Address - Street 1: | 560 S LOOP RD |
| Practice Address - Street 2: | |
| Practice Address - City: | EDGEWOOD |
| Practice Address - State: | KY |
| Practice Address - Zip Code: | 41017 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 859-301-2663 |
| Practice Address - Fax: | 859-301-0655 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-05-08 |
| Last Update Date: | 2022-08-23 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207QS0010X, 207RM1200X, 207X00000X, 207XS0114X, 208100000X, 213E00000X, 213ES0103X, 225100000X, 332B00000X, 363A00000X, 363AM0700X | ||
| KY | 207R00000X, 207XS0106X, 363L00000X, 363LF0000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RM1200X | Allopathic & Osteopathic Physicians | Internal Medicine | Magnetic Resonance Imaging (MRI) | Group - Multi-Specialty |
| No | 207XS0106X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | Group - Multi-Specialty |
| No | 207XS0114X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | Group - Multi-Specialty |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
| No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| KY | 80900186 | Other | MEDICAID PODIATRIST |
| KY | 7100185740 | Other | MEDICAID NURSE PRACTITIONER |
| KY | 90008962 | Other | MEDICAID DME |
| KY | 9590071800 | Other | MEDICAID PHYSICIAN ASSISTANT |
| KY | 7100147130 | Other | MEDICAID PHYSICAL THERAPIST |
| KY | 65927881 | Medicaid | |
| KY | 80900186 | Other | MEDICAID PODIATRIST |
| KY | 7100185740 | Other | MEDICAID NURSE PRACTITIONER |
| KY | 65927881 | Medicaid | |
| KY | 0428850008 | Medicare NSC | |
| KY | 0428850005 | Medicare NSC | |
| KY | CB8861 PALMETTO GBA | Medicare PIN |
