Provider Demographics
NPI:1891293924
Name:TEDTMAN, SAMUEL THOMAS (ATC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:THOMAS
Last Name:TEDTMAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 GRASMERE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1507
Mailing Address - Country:US
Mailing Address - Phone:502-767-3404
Mailing Address - Fax:
Practice Address - Street 1:GREAT AMERICAN BALL PARK
Practice Address - Street 2:100 JOE NUXHALL WAY
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202
Practice Address - Country:US
Practice Address - Phone:502-767-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT77502255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer