1871543025 NPI number — LARSON, BROUGH, AND BROCKMAN PSC

Table of content: (NPI 1871543025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871543025 NPI number — LARSON, BROUGH, AND BROCKMAN PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARSON, BROUGH, AND BROCKMAN PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871543025
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42002-9150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-744-9600
Provider Business Mailing Address Fax Number:
270-744-8642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5109 NEW CUT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40214-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-1197
Provider Business Practice Location Address Fax Number:
502-361-0090
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
DANA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PROVIDER ENROLLMENT SPECIALIST
Authorized Official Telephone Number:
270-744-9600

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100106000 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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