Provider Demographics
NPI:1336246412
Name:PHYSICAL THERAPY ASSOCIATES, INC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLLEY
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-360-9129
Mailing Address - Street 1:403 N MILES ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1834
Mailing Address - Country:US
Mailing Address - Phone:270-360-9129
Mailing Address - Fax:270-234-8197
Practice Address - Street 1:1222 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2710
Practice Address - Country:US
Practice Address - Phone:270-234-1569
Practice Address - Fax:270-234-0680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002884225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8790006400Medicaid
000000176398OtherANTHEM BLUE CROSS
X48767Medicare UPIN
KY8790006400Medicaid
KYCJ8198Medicare PIN