Healthcare Provider Details

I. General information

NPI: 1720680119
Provider Name (Legal Business Name): MIISPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 DUTCHMANS PKWY STE 160
LOUISVILLE KY
40205-3353
US

IV. Provider business mailing address

6420 DUTCHMANS PKWY STE 160
LOUISVILLE KY
40205-3353
US

V. Phone/Fax

Practice location:
  • Phone: 502-242-6370
  • Fax: 502-242-6540
Mailing address:
  • Phone: 502-242-6370
  • Fax: 502-242-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: VENU VEMURI
Title or Position: OWNER
Credential: DO
Phone: 502-242-6370