MEDICARE: CRYSTAL STEVENS LPT

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	2251X0800X	Orthopedic Physical Therapist	004317	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00417175	OTHER	KY	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000346353	OTHER	KY	ANTHEM BLUE SHIELD

General Provider Information

NPI Number	:	1205998630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL STEVENS LPT

Provider Business Mailing Address
First Line	:	9300 STONESTREET RD
Second Line	:	SUITE 400
City	:	LOUISVILLE
State	:	KY
Zip	:	40272-2876
Country	:	US
Telephone Number	:	502-935-9776
Fax Number	:	502-935-9813

Provider Business Practice Location Address
First Line	:	9300 STONESTREET RD
Second Line	:	SUITE 400
City	:	LOUISVILLE
State	:	KY
Zip	:	40272-2876
Country	:	US
Telephone Number	:	502-935-9776
Fax Number	:	502-935-9813

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	12/11/2007

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Directions to “ CRYSTAL STEVENS LPT” Practice Location

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