Provider Demographics
NPI:1508374315
Name:LOUISVILLE PHYSICAL MEDICINE PLLC
Entity Type:Organization
Organization Name:LOUISVILLE PHYSICAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY ASSURANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-694-2020
Mailing Address - Street 1:PO BOX 622
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-0622
Mailing Address - Country:US
Mailing Address - Phone:205-694-2020
Mailing Address - Fax:205-380-0354
Practice Address - Street 1:3999 DUTCHMANS LN STE 4C
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4745
Practice Address - Country:US
Practice Address - Phone:502-744-3239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26921208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000509322OtherANTHEM
KY50013453OtherPASSPORT
KY64269210Medicaid