Basic Information
| Provider Information | |||||||||
| NPI: | 1164743720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREEMAN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | LARRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 SWIFT BLVD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993523524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5096272983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 GOETHALS DRIVE 2ND FLOOR | ||||||||
| Address2: | KADLEC CLINIC FOOT & ANKLE | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993523304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5095470827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO60337485 | WA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 213ES0103X | OH | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 500657140 | 05 | OR | MEDICAID | 0312593 | 01 | WA | L&I | OTHER | 1164743720 | 05 | WA | MEDICAID |