Basic Information
| Provider Information | |||||||||
| NPI: | 1346228467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALBERTSON | ||||||||
| FirstName: | B | ||||||||
| MiddleName: | BRADLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALBERTSON | ||||||||
| OtherFirstName: | BYRON | ||||||||
| OtherMiddleName: | BRADLEY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192512032 | ||||||||
| FaxNumber: | 4192511485 | ||||||||
| Practice Location | |||||||||
| Address1: | 83 WELLNESS WAY | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420257156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705270045 | ||||||||
| FaxNumber: | 2705270075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 02826 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 02826 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64082555 | 05 | KY | MEDICAID |