Provider Demographics
NPI:1366482028
Name:BALDWIN, BRENT A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:A
Last Name:BALDWIN
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 1:975 EAST 3RD ST
Mailing Address - Street 2:BOX 376
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:423-778-7234
Mailing Address - Fax:
Practice Address - Street 1:4000 KRESGE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4605
Practice Address - Country:US
Practice Address - Phone:502-897-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY384492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00077253OtherMEDICARE RAILROAD
KY1285821Medicare PIN
GAP00077253OtherMEDICARE RAILROAD