Provider Demographics
NPI:1053389114
Name:MCKIBBEN, PATRICK RAYMOND (MPT)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:RAYMOND
Last Name:MCKIBBEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 CREEK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-8398
Mailing Address - Country:US
Mailing Address - Phone:513-733-9333
Mailing Address - Fax:513-588-2479
Practice Address - Street 1:4440 GLEN ESTE WITHAMSVILLE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1318
Practice Address - Country:US
Practice Address - Phone:513-943-3630
Practice Address - Fax:513-753-4308
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.011095225100000X
KYPT.0047812251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2750545Medicaid
OH000000502323OtherANTHEM
OH2750545Medicaid
OH000000502323OtherANTHEM