Provider Demographics
NPI:1548298433
Name:BEANBLOSSOM, BRIAN T (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:BEANBLOSSOM
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28243207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000693025OtherANTHEM - NCVA
IN200080790AMedicaid
KYP00889586OtherMEDICARE - RR - NCVA
KY1056108OtherPASSPORT PIN
KY64282437Medicaid
KY000057058XOtherHUMANA - NCVA
KY000057058XOtherHUMANA - NCVA
KYE20733Medicare UPIN
IN200080790AMedicaid
KY2433834000OtherPASSPORT ADVANTAGE PIN
KY0259820Medicare ID - Type Unspecified
IN200080790FMedicaid
IN200080790AMedicaid
KY060041699Medicare PIN