Healthcare Provider Details

I. General information

NPI: 1588674865
Provider Name (Legal Business Name): BERNARD THEODORE BOTILLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 HARRODSBURG ROAD SUITE D 304
LEXINGTON KY
40504
UM

IV. Provider business mailing address

6400 DUTCHMANS PKWY SUITE 250
LOUISVILLE KY
40205-3340
US

V. Phone/Fax

Practice location:
  • Phone: 859-977-4000
  • Fax: 859-977-5100
Mailing address:
  • Phone: 502-587-9660
  • Fax: 502-540-5615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA674
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA674
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: