Basic Information
| Provider Information | |||||||||
| NPI: | 1407982085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HITTEPOLE | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | BERG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY STE 290 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022178221 | ||||||||
| FaxNumber: | 5022175056 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST SUITE 370 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028136800 | ||||||||
| FaxNumber: | 5025626515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 03/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 42853 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3744367000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 7100085790 | 05 | KY | MEDICAID | 000000635639 | 01 | KY | ANTHEM | OTHER | 50026160 | 01 | KY | PASSPORT | OTHER | 200957520 | 05 | IN | MEDICAID |