Individual
BRIAN T BEANBLOSSOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
6420 DUTCHMANS PKWY, SUITE 200, LOUISVILLE, KY 40205-3372
(502) 891-8300
Mailing address
PO BOX 776351, CHICAGO, IL 60677-6351
(502) 588-9490
(502) 272-5116
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
28243
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000693025
ANTHEM - NCVA
KY
01
—
000057058X
HUMANA - NCVA
KY
01
—
1056108
PASSPORT PIN
KY
05
—
200080790A
—
IN
05
—
64282437
—
KY
01
—
P00889586
MEDICARE - RR - NCVA
KY
Enumeration date
06/29/2006
Last updated
01/12/2021
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