Provider Demographics
NPI:1558629410
Name:GISH, BRANDON ERIK (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:ERIK
Last Name:GISH
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 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:1221 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-6101
Practice Address - Fax:859-258-4411
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49444207LP2900X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100275660Medicaid
IN300009866Medicaid
000001085596OtherANTHEM PIN
KY1529942OtherWELLCARE OF KY PROVIDER ID NUMBER
KY7100275660Medicaid
CS1724201468OtherCARESOURCE ID
IN300009866Medicaid
6465713OtherUNITED HEALTHCARE PROVIDER ID NUMBER