Provider Demographics
NPI:1689070559
Name:SPORTS MEDICINE SURGICAL SPECIALISTS PLLC
Entity Type:Organization
Organization Name:SPORTS MEDICINE SURGICAL SPECIALISTS PLLC
Other - Org Name:KENTUCKIANA FOOT AND ANKLE SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:WELLINGTON
Authorized Official - Last Name:MYRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:502-721-8288
Mailing Address - Street 1:6400 DUTCHMANS PKWY
Mailing Address - Street 2:# 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 STE 215
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3343
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:2014-11-05
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
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
KY7100333220Medicaid
KY7100333220Medicaid
KYK182510Medicare PIN
ININ2284Medicare PIN