Basic Information
| Provider Information | |||||||||
| NPI: | 1679876353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRANNON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 258 | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 258 | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2010 | ||||||||
| LastUpdateDate: | 06/12/2012 | ||||||||
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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 | 207L00000X | 2009018186 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 03376 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0062255 | 05 | OH | MEDICAID | 40531238600 | 01 | OH | BUREAU OF WORKERS COMPENSATION | OTHER | 201042850 | 05 | IN | MEDICAID | 000000720844 | 01 | OH | ANTHEM BLUE SHIELD | OTHER | 7100173380 | 05 | KY | MEDICAID |