Provider Demographics
NPI:1841261914
Name:PHOENIX REHAB GROUP, LLC
Entity type:Organization
Organization Name:PHOENIX REHAB GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-781-0028
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-0391
Mailing Address - Country:US
Mailing Address - Phone:270-781-0028
Mailing Address - Fax:270-781-0007
Practice Address - Street 1:1600 SCOTTSVILLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3217
Practice Address - Country:US
Practice Address - Phone:270-781-0028
Practice Address - Fax:270-781-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101011261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000375294OtherANTHEM GROUP SLP
KY2224590OtherFIRST HEALTH
KY87900817Medicaid
KY000000375301OtherANTHEM GROUP PT
KY88900071Medicaid
KY000000337293OtherANTHEM GROUP OT
KY91000042Medicaid
KY2224590OtherFIRST HEALTH
KY88900071Medicaid
KY91000042Medicaid
KY000000337293OtherANTHEM GROUP OT
KYDE3129Medicare Oscar/Certification
KY=========OtherBLUEGRASS FAMILY HEALTH
KY87900817Medicaid