Healthcare Provider Details

I. General information

NPI: 1376729905
Provider Name (Legal Business Name): BRANDIE CARMEN CHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 TURFWAY RD
FLORENCE KY
41042-1375
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-212-5025
  • Fax: 859-212-4432
Mailing address:
  • Phone: 859-212-5025
  • Fax: 859-212-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number64345
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number064345
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49021
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTP864
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: