Healthcare Provider Details

I. General information

NPI: 1598219412
Provider Name (Legal Business Name): BRADLEY J BURKHART PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 RING RD STE 200
ELIZABETHTOWN KY
42701-5913
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-5926
  • Fax:
Mailing address:
  • Phone: 502-588-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC497
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2121
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: