Healthcare Provider Details

I. General information

NPI: 1245744598
Provider Name (Legal Business Name): BRENT EDWARD MEZGER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2017
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 S COLLEGE MALL RD
BLOOMINGTON IN
47401-6177
US

IV. Provider business mailing address

2620 ELM HILL PIKE
NASHVILLE TN
37214-3108
US

V. Phone/Fax

Practice location:
  • Phone: 812-323-4301
  • Fax:
Mailing address:
  • Phone: 937-369-8865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007721A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.021975
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: