Healthcare Provider Details

I. General information

NPI: 1740487651
Provider Name (Legal Business Name): ROBERT EUGENE LOUDERMILK II PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 COMMERCE CROSSINGS DR STE 100
LOUISVILLE KY
40229-2192
US

IV. Provider business mailing address

300 CRATOR DR
LOUISVILLE KY
40229-6120
US

V. Phone/Fax

Practice location:
  • Phone: 502-968-9110
  • Fax:
Mailing address:
  • Phone: 502-957-3355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA02204
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: