Healthcare Provider Details

I. General information

NPI: 1033601091
Provider Name (Legal Business Name): ORTHOCINCY ORTHOPAEDICS & SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

IV. Provider business mailing address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

V. Phone/Fax

Practice location:
  • Phone: 859-817-7500
  • Fax: 859-817-7851
Mailing address:
  • Phone: 859-817-7500
  • Fax: 859-817-7851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLENE MOORE
Title or Position: MANAGER
Credential:
Phone: 859-817-7500