Provider Demographics
NPI:1811148547
Name:REHAB ON THE ROAD, PSC
Entity type:Organization
Organization Name:REHAB ON THE ROAD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:MOOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:502-645-1053
Mailing Address - Street 1:800 MAN O WAR BLVD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:KY
Mailing Address - Zip Code:41091-8067
Mailing Address - Country:US
Mailing Address - Phone:502-645-1053
Mailing Address - Fax:888-390-7623
Practice Address - Street 1:800 MAN O WAR BLVD
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:KY
Practice Address - Zip Code:41091-8067
Practice Address - Country:US
Practice Address - Phone:502-645-1053
Practice Address - Fax:888-390-7623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31321208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000074661OtherANTHEM PROVIDER #
IN200179480AMedicaid
KY1102772OtherPASSPORT
KY2436318000OtherPASSPORT ADVANTAGE
KY64-313216Medicaid
INP00003391OtherRAILROAD
KY1285608752OtherNPI
KY250010583OtherRAILROAD
INP00003391OtherRAILROAD
KY0078118Medicare PIN
KYG63159Medicare UPIN