Healthcare Provider Details

I. General information

NPI: 1770582561
Provider Name (Legal Business Name): BRIAN S GILLISPIE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 HARRODSBURG RD STE 100
LEXINGTON KY
40503-2747
US

IV. Provider business mailing address

1221 S BROADWAY
LEXINGTON KY
40504-2701
US

V. Phone/Fax

Practice location:
  • Phone: 859-277-6102
  • Fax: 859-977-0237
Mailing address:
  • Phone: 859-258-6200
  • Fax: 859-258-6203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number02660
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number02660
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: