Basic Information
| Provider Information | |||||||||
| NPI: | 1033245055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRISCOE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY STE 129 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534900 | ||||||||
| FaxNumber: | 5024895751 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 TRILLIUM WAY | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065238521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 16130 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | P01458485 | 01 | KY | RR MEDICARE | OTHER | C15173 | 01 | KY | CUMBERLAND HEALTHCARE, IN | OTHER | 64161300 | 05 | KY | MEDICAID |