Provider Demographics
NPI:1629189105
Name:HAMMOND, BETHANIE RAE (MD)
Entity Type:Individual
Prefix:
First Name:BETHANIE
Middle Name:RAE
Last Name:HAMMOND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5129 DIXIE HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-1727
Mailing Address - Country:US
Mailing Address - Phone:502-447-8786
Mailing Address - Fax:502-447-8623
Practice Address - Street 1:5129 DIXIE HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1727
Practice Address - Country:US
Practice Address - Phone:502-447-8786
Practice Address - Fax:502-447-8623
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE275642085R0202X
KS04368272085R0202X
CO530122085R0202X
MA2464372085R0202X
KY475092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1629189105Medicaid
NM63780062Medicaid
AZ899230Medicaid
NE84059792913Medicaid
UT1629189105Medicaid
KY7100325960Medicaid
NE84089712600Medicaid
IN200840750Medicare PIN
NE84059792913Medicaid
KY7100325960Medicaid
CO326932YQPGMedicare PIN
MT1629189105Medicaid
NM63780062Medicaid
NENA1214083Medicare PIN
NENA1215083Medicare PIN
KS111257071Medicare PIN
CO326932YQN9Medicare PIN
UT1629189105Medicaid
KSKA3249044Medicare PIN