Basic Information
| Provider Information | |||||||||
| NPI: | 1528062189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WETHERTON | ||||||||
| FirstName: | BRENDEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004768646 | ||||||||
| FaxNumber: | 9193823210 | ||||||||
| Practice Location | |||||||||
| Address1: | 727 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400651660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026474347 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207P00000X | 35884 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64035520 | 05 | KY | MEDICAID | 000000060164 | 01 | KY | BCBS GROUP # | OTHER | 000000275811 | 01 | KY | BCBS GROUP # SAME | OTHER |