Provider Demographics
NPI: | 1003470469 |
---|---|
Name: | BRICKNELL, RYAN AZIZ THOMAS (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RYAN |
Middle Name: | AZIZ THOMAS |
Last Name: | BRICKNELL |
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: | 200 E CHESTNUT ST BLDG SUITE303 |
Practice Address - Street 2: | |
Practice Address - City: | LOUISVILLE |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40202-1831 |
Practice Address - Country: | US |
Practice Address - Phone: | 502-629-5552 |
Practice Address - Fax: | 502-629-3132 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2019-04-30 |
Last Update Date: | 2023-03-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
KY | 56599 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 7100881830 | Medicaid | |
KY | 56599 | Other | STATE LICENSE |