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General NPI Number Information
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NPI Number | 1871543025
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Entity Type | Organization
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Legal Business Name | LARSON, BROUGH, AND BROCKMAN PSC
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Dates
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Enumeration Date | 05/10/2006
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Last Update Date | 08/22/2011
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Provider Practice Location Address
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Address Line | 5109 NEW CUT RD
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City | LOUISVILLE
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State | KY
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Zip | 40214-2745
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Country | US
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Telephone | 502-361-1197
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Fax | 502-361-0090
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Provider Business Mailing Address
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Address Line | PO BOX 9150
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City | PADUCAH
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State | KY
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Zip | 42002-9150
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Country | US
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Telephone | 270-744-9600
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Fax | 270-744-8642
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Authorized Official
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Title or Position | PROVIDER ENROLLMENT SPECIALIST
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Name | DANA L EVANS
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Credential |
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Telephone | 270-744-9600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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