Basic Information
| Provider Information | |||||||||
| NPI: | 1912004649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEWCOM | ||||||||
| FirstName: | BRADLY | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23229 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423043229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706881330 | ||||||||
| FaxNumber: | 2706881338 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 RUBY DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424312168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703997900 | ||||||||
| FaxNumber: | 2703997910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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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 | 39210 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0000X | 39210 | KY | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000362048 | 01 | BCBS PROVIDER NUMBER | OTHER | 64098379 | 05 | KY | MEDICAID | 39210 | 01 | KY | LICENSE | OTHER |