Provider Demographics
NPI:1174526487
Name:SPECIALTY ORTHOPAEDICS PSC
Entity type:Organization
Organization Name:SPECIALTY ORTHOPAEDICS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-721-8288
Mailing Address - Street 1:6400 DUTCHMANS PKWY
Mailing Address - Street 2:STE 215
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3343
Mailing Address - Country:US
Mailing Address - Phone:502-721-8288
Mailing Address - Fax:502-721-8792
Practice Address - Street 1:6400 DUTCHMANS PKWY
Practice Address - Street 2:STE 215
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3343
Practice Address - Country:US
Practice Address - Phone:502-721-8288
Practice Address - Fax:502-721-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32683207XS0106X
KY00251213ES0103X
332B00000X
KY31883207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65915308Medicaid
KY1129663OtherGRP PASSPORT
KYDE3727OtherGRP RAILROAD MEDICARE
KY80900293OtherGRP MEDICAID PODIATRY
KY0670801Medicare PIN