Healthcare Provider Details

I. General information

NPI: 1104343490
Provider Name (Legal Business Name): PHYSICIANS HEALTH GROUP OF KENTUCKY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BRECKENRIDGE LN STE 20
LOUISVILLE KY
40207-5931
US

IV. Provider business mailing address

950 BRECKENRIDGE LN STE 20
LOUISVILLE KY
40207-5931
US

V. Phone/Fax

Practice location:
  • Phone: 859-687-9456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOHN RUSH
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 301-928-1697