Provider Demographics
NPI:1013013028
Name:MCENTIRE, BRENT E (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:E
Last Name:MCENTIRE
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 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4420 DIXIE HWY
Practice Address - Street 2:STE. 114
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2988
Practice Address - Country:US
Practice Address - Phone:502-449-6464
Practice Address - Fax:502-449-6465
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35588207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64018401Medicaid
000000194158OtherBCBS PROVIDER NUMBER
KY35588OtherLICENSE
KY64018401Medicaid
0525670Medicare PIN
0375278Medicare PIN
0374774Medicare PIN
0374682Medicare PIN
0375375Medicare PIN
KY00280142Medicare PIN
000000194158OtherBCBS PROVIDER NUMBER
0375176Medicare PIN
0536390Medicare PIN
0600231Medicare PIN
KY35588OtherLICENSE
0396810Medicare PIN