Provider Demographics
NPI:1104946540
Name:PAVKOVICH, RONALD KEITH (DPT)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:KEITH
Last Name:PAVKOVICH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 SUMMIT SQUARE PL STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2642
Mailing Address - Country:US
Mailing Address - Phone:859-263-8080
Mailing Address - Fax:859-263-8080
Practice Address - Street 1:3217 SUMMIT SQUARE PL STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2642
Practice Address - Country:US
Practice Address - Phone:859-263-8080
Practice Address - Fax:859-263-8080
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100182650Medicaid
KY000000741682OtherANTHEM PIN
KY9352829OtherAETNA PIN
KYK020790Medicare PIN
KY00633413Medicare PIN