=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245589217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXTREMITY CENTER OF KENTUCKIANA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2012
-----------------------------------------------------
Last Update Date | 10/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 EASTPOINT PKWY STE 560
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40223-4154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-365-4545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12418 LA GRANGE RD STE 145
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40245-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | ROBERT HOBBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-365-4545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 0834564
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------