Basic Information
| Provider Information | |||||||||
| NPI: | 1407131907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | VAIL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593443945 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593441600 | ||||||||
| FaxNumber: | 8593440091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2011 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 04179 | KY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100499880 | 05 | KY | MEDICAID | 0237674 | 05 | OH | MEDICAID |