Provider Demographics
NPI:1316020951
Name:GREENWELL, BERNARD DAMON (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:DAMON
Last Name:GREENWELL
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 1:596 WALNUT HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701
Mailing Address - Country:US
Mailing Address - Phone:270-765-4255
Mailing Address - Fax:
Practice Address - Street 1:222 WEST DIXIE AVENUE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701
Practice Address - Country:US
Practice Address - Phone:270-769-1219
Practice Address - Fax:270-769-5123
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1065979OtherPASSPORT
KY64134745Medicaid
C70867Medicare UPIN
KY64134745Medicaid