Healthcare Provider Details

I. General information

NPI: 1386089324
Provider Name (Legal Business Name): BRENT MICHAEL LINDSLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEDICAL CENTER DR
PADUCAH KY
42003-7914
US

IV. Provider business mailing address

225 MEDICAL CENTER DR STE 405
PADUCAH KY
42003-7914
US

V. Phone/Fax

Practice location:
  • Phone: 270-441-4750
  • Fax: 270-441-4770
Mailing address:
  • Phone: 270-441-4750
  • Fax: 270-441-4770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number123456
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number04136
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: