Healthcare Provider Details

I. General information

NPI: 1093764847
Provider Name (Legal Business Name): KENNETH BRODSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 LINVILLE DR SUITE 104
PARIS KY
40361-2165
US

IV. Provider business mailing address

5 LINVILLE DR SUITE 104
PARIS KY
40361-2165
US

V. Phone/Fax

Practice location:
  • Phone: 859-987-8432
  • Fax: 859-987-8433
Mailing address:
  • Phone: 859-987-8432
  • Fax: 859-987-8433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02928
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: