Basic Information
| Provider Information | |||||||||
| NPI: | 1952060485 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROREHAB OF LOUISVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5629 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477165629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124013258 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4042 DUTCHMANS LN | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028999363 | ||||||||
| FaxNumber: | 5028999365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2021 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | BAUMANN | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8127597473 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 1952060485 | 05 | KY | MEDICAID |