Healthcare Provider Details

I. General information

NPI: 1376945329
Provider Name (Legal Business Name): JOHN W POLK IV PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S BROADWAY ST STE 12
GEORGETOWN KY
40324-2300
US

IV. Provider business mailing address

808 S BROADWAY ST STE 12
GEORGETOWN KY
40324-2300
US

V. Phone/Fax

Practice location:
  • Phone: 502-427-6004
  • Fax: 502-427-0411
Mailing address:
  • Phone: 502-427-6004
  • Fax: 502-427-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number006531
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: