Basic Information
| Provider Information | |||||||||
| NPI: | 1629189105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAMMOND | ||||||||
| FirstName: | BETHANIE | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5129 DIXIE HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402161727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024478786 | ||||||||
| FaxNumber: | 5024478623 | ||||||||
| Practice Location | |||||||||
| Address1: | 5129 DIXIE HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402161727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024478786 | ||||||||
| FaxNumber: | 5024478623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 27564 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0436827 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 53012 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 246437 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 47509 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1629189105 | 05 | MT | MEDICAID | 63780062 | 05 | NM | MEDICAID | 899230 | 05 | AZ | MEDICAID | 84059792913 | 05 | NE | MEDICAID | 1629189105 | 05 | UT | MEDICAID | 7100325960 | 05 | KY | MEDICAID | 84089712600 | 05 | NE | MEDICAID |