Provider Demographics
NPI:1982618393
Name:COMMONWEALTH REHABILITATION & SPORTS MEDICINE PSC
Entity Type:Organization
Organization Name:COMMONWEALTH REHABILITATION & SPORTS MEDICINE PSC
Other - Org Name:COMMONWEALTH PHYSICAL THERAPY AND REHABILITATION- BURLINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:859-278-2121
Mailing Address - Street 1:PO BOX 911148
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40591-1148
Mailing Address - Country:US
Mailing Address - Phone:859-278-2121
Mailing Address - Fax:859-276-6149
Practice Address - Street 1:5874 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KY
Practice Address - Zip Code:41005-8824
Practice Address - Country:US
Practice Address - Phone:859-334-4331
Practice Address - Fax:859-586-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000393665OtherANTHEM PROVIDER NUMBER
41219083603OtherOHIO BWC PROVIDER NUMBER