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General NPI Number Information
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NPI Number | 1881031680
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Entity Type | Organization
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Legal Business Name | BRECKENRIDGE MEDICAL GROUP, PSC
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Dates
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Enumeration Date | 06/03/2013
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Last Update Date | 06/03/2013
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Provider Practice Location Address
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Address Line | 974 BRECKENRIDGE LN SUITE 133
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City | LOUISVILLE
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State | KY
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Zip | 40207-4619
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Country | US
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Telephone | 502-909-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 974 BRECKENRIDGE LN SUITE 133
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City | LOUISVILLE
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State | KY
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Zip | 40207-4619
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Country | US
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Telephone | 502-909-3300
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | TAMMY CARPENTER
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Credential |
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Telephone | 502-909-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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