Basic Information
| Provider Information | |||||||||
| NPI: | 1912045212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRISCOE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY STE 129 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534900 | ||||||||
| FaxNumber: | 5024895751 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E. CHESTNUT ST. | ||||||||
| Address2: | STE 610 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028136600 | ||||||||
| FaxNumber: | 5028136650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 43198 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | P01458486 | 01 | KY | RR MEDICARE | OTHER | 7100107260 | 05 | KY | MEDICAID |