Provider Demographics
NPI:1396935854
Name:KNOX ORTHOPAEDIC & SPORTS MEDICINE CENTER, LLC
Entity type:Organization
Organization Name:KNOX ORTHOPAEDIC & SPORTS MEDICINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, ORTHOPEDIC SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:DOOLITTLE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:740-393-2226
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-0487
Mailing Address - Country:US
Mailing Address - Phone:740-393-2226
Mailing Address - Fax:740-393-2220
Practice Address - Street 1:1375 YAUGER RD
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-8939
Practice Address - Country:US
Practice Address - Phone:740-393-2226
Practice Address - Fax:740-393-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-053777207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2332881Medicaid
OHKN 9321281Medicare PIN
OH2332881Medicaid