Provider Demographics
NPI:1902894983
Name:BROADBENT, JOHN E (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S 8TH ST
Mailing Address - Street 2:STE 480W
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2400
Mailing Address - Country:US
Mailing Address - Phone:270-762-1560
Mailing Address - Fax:270-752-2861
Practice Address - Street 1:300 S 8TH ST
Practice Address - Street 2:STE 182W
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2400
Practice Address - Country:US
Practice Address - Phone:270-762-1560
Practice Address - Fax:270-752-2861
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29485174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000215823OtherBLUE CROSS BLUE SHIELD
KY5196668OtherAETNA
KY2500783OtherUNITED HEALTH
KY64294853Medicaid
KYF66923Medicare UPIN
KYQ37299Medicare UPIN
KY64294853Medicaid