Provider Demographics
NPI:1184620098
Name:PITCOCK, LOUIE DENNIS JR (MPT)
Entity type:Individual
Prefix:
First Name:LOUIE
Middle Name:DENNIS
Last Name:PITCOCK
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-5024
Mailing Address - Country:US
Mailing Address - Phone:270-781-1151
Mailing Address - Fax:270-781-5990
Practice Address - Street 1:2235 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-5024
Practice Address - Country:US
Practice Address - Phone:270-781-1151
Practice Address - Fax:270-781-5990
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87000964Medicaid
7317410OtherAETNA
KY000000244257OtherANTHEM
683303Medicare ID - Type Unspecified