Basic Information
| Provider Information | |||||||||
| NPI: | 1588619449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PT PROS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 383 CORBIN CENTER DR | ||||||||
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| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407011895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065262909 | ||||||||
| FaxNumber: | 6065262901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1138 S HIGHWAY 27 | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425013523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066772006 | ||||||||
| FaxNumber: | 6066771779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAUSER | ||||||||
| AuthorizedOfficialFirstName: | CONNIE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6065262918 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | P.T | ||||||||
| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7202 | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 87900411 | 05 | KY | MEDICAID | 186643 | 01 | KY | CGS ADMIN PART A MEDICARE | OTHER | 000000059824 | 01 | KY | BCBS NUMBER | OTHER |