Healthcare Provider Details

I. General information

NPI: 1003212630
Provider Name (Legal Business Name): BRANDON COWAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 NEWCOMB AVE
MOUNT VERNON KY
40456
US

IV. Provider business mailing address

140 NEWCOMB AVE
MOUNT VERNON KY
40456-2725
US

V. Phone/Fax

Practice location:
  • Phone: 606-256-4148
  • Fax: 606-256-5191
Mailing address:
  • Phone: 606-256-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR3971
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51005
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number51005
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01086775A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: