Provider Demographics
NPI:1548303696
Name:OSBORNE, BRENDA ALEXIS (MD)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:ALEXIS
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 PRESTON HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-1820
Mailing Address - Country:US
Mailing Address - Phone:502-893-5502
Mailing Address - Fax:502-721-8670
Practice Address - Street 1:720 W BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2240
Practice Address - Country:US
Practice Address - Phone:502-593-5502
Practice Address - Fax:502-583-1330
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1102093OtherPASSPORT
KY1104973OtherPASSPORT
KY1104978OtherPASSPORT
KY1072555OtherPASSPORT
KY64327810Medicaid
KY000000066734OtherANTHEM
KY000000066734OtherANTHEM