Provider Demographics
NPI:1982678140
Name:WISDOM, RODNEY QUINN (DC)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:QUINN
Last Name:WISDOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 BERKSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1155
Mailing Address - Country:US
Mailing Address - Phone:502-499-7744
Mailing Address - Fax:502-499-4928
Practice Address - Street 1:5306 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-1931
Practice Address - Country:US
Practice Address - Phone:502-499-7744
Practice Address - Fax:502-499-4928
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4078111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY270696OtherPHCS
KY8735432OtherCIGNA
KYDD7594OtherRAILROAD MEDICARE GROUP #
KY7993OtherMEDICARE GROUP NUMBER
KY000000375026OtherBLUE CROSS BLUE SHIELD
KY000000375026OtherBLUE CROSS BLUE SHIELD
KY7993OtherMEDICARE GROUP NUMBER