MEDICARE: CORY STATLER DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1174230197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORY STATLER DPT

Provider Business Mailing Address
First Line	:	1650 LYNDON FARM CT STE 300
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-5005
Country	:	US
Telephone Number	:	502-576-3282
Fax Number	:

Provider Business Practice Location Address
First Line	:	3525 UNIVERSITY AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-2140
Country	:	US
Telephone Number	:	608-467-3537
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	10/31/2022

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