Basic Information
| Provider Information | |||||||||
| NPI: | 1902894983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADBENT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 300 S 8TH ST | ||||||||
| Address2: | STE 480W | ||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420712400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707621560 | ||||||||
| FaxNumber: | 2707522861 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 8TH ST | ||||||||
| Address2: | STE 182W | ||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420712400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707621560 | ||||||||
| FaxNumber: | 2707522861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 29485 | KY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000000215823 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER | 5196668 | 01 | KY | AETNA | OTHER | 2500783 | 01 | KY | UNITED HEALTH | OTHER | 64294853 | 05 | KY | MEDICAID |