Basic Information
| Provider Information | |||||||||
| NPI: | 1679764534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEFADE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | PHILIP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 SAINT CHRISTOPHER DR | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068333333 | ||||||||
| FaxNumber: | 6068334668 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 SAINT CHRISTOPHER DR | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068333333 | ||||||||
| FaxNumber: | 6068334668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 08/26/2010 | ||||||||
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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 | 208800000X | 03268 | KY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3062680 | 05 | OH | MEDICAID | 000000665202 | 01 | KY | ANTHEM BCBS | OTHER | 7100120830 | 05 | KY | MEDICAID |