Provider Demographics
NPI:1063402287
Name:BROTT, EDWIN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:THOMAS
Last Name:BROTT
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 1:2208 SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45233-4267
Mailing Address - Country:US
Mailing Address - Phone:513-300-0149
Mailing Address - Fax:
Practice Address - Street 1:2204 LEXINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:513-300-0149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31144207L00000X
OH62695207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000388319OtherANTHEM BLUE SHIELD
KY64311442Medicaid
IN200366710Medicaid
5087130OtherAETNA
173664OtherPRIVATE HEALTH CARE
000000351385OtherANTHEM BLUE SHIELD
OH0950047Medicaid
P00192341Medicare PIN
KY0918102Medicare ID - Type Unspecified
IN200366710Medicaid
KY64311442Medicaid
050087328Medicare PIN