Provider Demographics
NPI:1821651852
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:OWNER/AUTHORIZED OFFICIAL
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 STE 215
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3343
Mailing Address - Country:US
Mailing Address - Phone:502-721-8288
Mailing Address - Fax:502-721-8792
Practice Address - Street 1:210 E GRAY ST # 820
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-585-3668
Practice Address - Fax:502-585-3662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty