Healthcare Provider Details

I. General information

NPI: 1396302535
Provider Name (Legal Business Name): KYLE BRANDON POLLEY STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 NEW MOODY LN STE 102
LA GRANGE KY
40031-9183
US

IV. Provider business mailing address

1901 CAMPUS PL
LOUISVILLE KY
40299-2308
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-0598
  • Fax: 502-222-7446
Mailing address:
  • Phone: 502-222-0598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number61083
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: