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NPI Code Detail

MEDICARE: CHRISTINA GORMASTIC GILLES DPT

MEDICARE: CHRISTINA GORMASTIC GILLES DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialist004448KY
2225100000XPhysical Therapist05008800AIN
3225100000XPhysical Therapist004448KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1000000064465OTHERKYANTHEM/BCBS

General Provider Information

NPI Number : 1417963240
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHRISTINA GORMASTIC GILLES DPT
Provider Business Mailing Address
First Line : PO BOX 950248
Second Line :
City : LOUISVILLE
State : KY
Zip : 40295-0248
Country : US
Telephone Number : 502-489-5730
Fax Number : 502-489-5733
Provider Business Practice Location Address
First Line : 3303 FERN VALLEY RD
Second Line :
City : LOUISVILLE
State : KY
Zip : 40213-3529
Country : US
Telephone Number : 502-964-4889
Fax Number : 502-964-9769
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/01/2006
Last Update Date : 12/02/2020

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