Healthcare Provider Details

I. General information

NPI: 1487911095
Provider Name (Legal Business Name): BRENDEN KOOTSEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 HARRIS RD
KILMARNOCK VA
22482
US

IV. Provider business mailing address

86 HARRIS RD
KILMARNOCK VA
22482-3845
US

V. Phone/Fax

Practice location:
  • Phone: 804-435-1152
  • Fax: 804-434-8080
Mailing address:
  • Phone: 804-435-1152
  • Fax: 804-435-8080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52671
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101264322
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: