Provider Demographics
NPI:1043265069
Name:SHOUSE, BRYAN A (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:A
Last Name:SHOUSE
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 1:1 PHYSICIANS PARK
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-4107
Mailing Address - Country:US
Mailing Address - Phone:502-223-7629
Mailing Address - Fax:502-223-9829
Practice Address - Street 1:1 PHYSICIANS PARK
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4107
Practice Address - Country:US
Practice Address - Phone:502-223-7629
Practice Address - Fax:502-223-9829
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39886208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY17-00426OtherUNITED HEALTHCARE
KYH19838OtherBLUEGRASS FAMILY HEALTH
KY64017320Medicaid
KY000000109039OtherANTHEM PIN
KY64017320Medicaid
KY1275207Medicare PIN