Provider Demographics
NPI:1144693631
Name:KIDWELL, MICHAEL ANTHONY (PT, DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:KIDWELL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 WESTPORT RD
Mailing Address - Street 2:200
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3819
Mailing Address - Country:US
Mailing Address - Phone:270-766-1213
Mailing Address - Fax:270-766-1115
Practice Address - Street 1:708 WESTPORT RD
Practice Address - Street 2:200
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-3819
Practice Address - Country:US
Practice Address - Phone:270-766-1213
Practice Address - Fax:270-766-1115
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist