Provider Demographics
NPI:1780713842
Name:THOMAS, MADONNA RENEE (PT)
Entity type:Individual
Prefix:MS
First Name:MADONNA
Middle Name:RENEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4919
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:7725 HIGHWAY 62 STE 300
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-9676
Practice Address - Country:US
Practice Address - Phone:812-256-2147
Practice Address - Fax:812-256-2252
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001334225100000X
IN05002013A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000230208OtherANTHEM PROVIDER #
IN200432370Medicaid
INP00069385OtherMEDICARE RAILROAD
IN200432370Medicaid