Provider Demographics
NPI:1528062189
Name:WETHERTON, BRENDEN M (MD)
Entity type:Individual
Prefix:
First Name:BRENDEN
Middle Name:M
Last Name:WETHERTON
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:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0008
Mailing Address - Country:US
Mailing Address - Phone:800-476-8646
Mailing Address - Fax:919-382-3210
Practice Address - Street 1:727 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1660
Practice Address - Country:US
Practice Address - Phone:502-647-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35884207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64035520Medicaid
KY000000060164OtherBCBS GROUP #
KY000000275811OtherBCBS GROUP # SAME
KY0512306Medicare ID - Type UnspecifiedMEDICARE GROUP # 5123
KY000000060164OtherBCBS GROUP #
KYH36707Medicare UPIN