Healthcare Provider Details

I. General information

NPI: 1790751022
Provider Name (Legal Business Name): PHILLIP DANIEL BROOKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR BLANCHFIELD ARMY COMMUNITY HOSPITAL
FT. CAMPBELL KY
42223-5349
US

IV. Provider business mailing address

650 JOEL DR BLANCHFIELD ARMY COMMUNITY HOSPITAL
FT. CAMPBELL KY
42223-5349
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8372
  • Fax:
Mailing address:
  • Phone: 270-798-8372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number46386-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: