Organization
LARSON, BROUGH, AND BROCKMAN PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DANA L EVANS (PROVIDER ENROLLMENT SPECIALIST)
(270) 744-9600
Entity
Organization
Contact information
Practice address
5109 NEW CUT RD, LOUISVILLE, KY 40214-2745
(502) 361-1197
(502) 361-0090
Mailing address
PO BOX 9150, PADUCAH, KY 42002-9150
(270) 744-9600
(270) 744-8642
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100106000
—
KY
Enumeration date
05/10/2006
Last updated
08/22/2011
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