Provider Demographics
NPI:1386696821
Name:MADISON, BRENT A (MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:A
Last Name:MADISON
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 1:2323 LIME KILN LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3416
Mailing Address - Country:US
Mailing Address - Phone:502-339-8000
Mailing Address - Fax:
Practice Address - Street 1:309 11TH ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-1435
Practice Address - Country:US
Practice Address - Phone:502-732-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33995207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64059348Medicaid
KYG87357Medicare UPIN