Provider Demographics
NPI:1992832679
Name:ADVANCED ORTHOPAEDICS AND SPORTS MEDICINE OF KY PLLC
Entity Type:Organization
Organization Name:ADVANCED ORTHOPAEDICS AND SPORTS MEDICINE OF KY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:CERVONI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-624-4110
Mailing Address - Street 1:789 EASTERN BYP STE 5
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2407
Mailing Address - Country:US
Mailing Address - Phone:859-624-4110
Mailing Address - Fax:859-624-1968
Practice Address - Street 1:789 EASTERN BYP STE 5
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2407
Practice Address - Country:US
Practice Address - Phone:859-624-4110
Practice Address - Fax:859-624-1968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000311396OtherBLUECROSS BLUESHIELD
KY65940025Medicaid
KYDB5273OtherTRAVELERS MEDICARE
KYDB5273OtherTRAVELERS MEDICARE
KY5245840001Medicare NSC
KY65940025Medicaid