Basic Information
| Provider Information | |||||||||
| NPI: | 1548298433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEANBLOSSOM | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 6420 DUTCHMANS PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402053372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028918300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 28243 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000000693025 | 01 | KY | ANTHEM - NCVA | OTHER | 200080790A | 05 | IN | MEDICAID | P00889586 | 01 | KY | MEDICARE - RR - NCVA | OTHER | 1056108 | 01 | KY | PASSPORT PIN | OTHER | 64282437 | 05 | KY | MEDICAID | 000057058X | 01 | KY | HUMANA - NCVA | OTHER |