Basic Information
| Provider Information | |||||||||
| NPI: | 1548268584 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREWER | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 708 OVERTON ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410712065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598664749 | ||||||||
| FaxNumber: | 5136317484 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 OVERTON ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410712065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598664749 | ||||||||
| FaxNumber: | 5136317484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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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 | 208000000X | 19083 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64190838 | 05 | KY | MEDICAID | 00000003752 | 01 | KY | ANTHEM | OTHER |