Basic Information
| Provider Information | |||||||||
| NPI: | 1174757900 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BEHRENDT | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LIBERTY ST | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023151459 | ||||||||
| FaxNumber: | 5024791425 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 LONDON MOUNTAIN VIEW DR | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407416601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068640770 | ||||||||
| FaxNumber: | 6068641461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 03/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TC016 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA1195 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100093470 | 05 | KY | MEDICAID |