Healthcare Provider Details

I. General information

NPI: 1508218504
Provider Name (Legal Business Name): BRENTLEY FROSSARD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 LONE OAK RD
PADUCAH KY
42003-4526
US

IV. Provider business mailing address

546 LONE OAK RD
PADUCAH KY
42003-4526
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-3647
  • Fax: 270-442-3777
Mailing address:
  • Phone: 270-442-3647
  • Fax: 270-442-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number05883
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number05883
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: