Basic Information
| Provider Information | |||||||||
| NPI: | 1871543025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LARSON, BROUGH, AND BROCKMAN PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 5109 NEW CUT RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402142745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023611197 | ||||||||
| FaxNumber: | 5023610090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2707449600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100106000 | 05 | KY | MEDICAID |