Provider Demographics
NPI:1821028481
Name:BROUDY, BRUCE CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:CHARLES
Last Name:BROUDY
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 1:1225 S. BROADWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-4568
Mailing Address - Fax:859-258-4698
Practice Address - Street 1:1225 S. BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-4568
Practice Address - Fax:859-258-4698
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18112207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYASC1019OtherMEDICARE ASC GROUP
KY37903705OtherMEDICAID LAB GROUP
KY64181126Medicaid
KY4000501OtherMEDICARE LAB GROUP
KYCB5773OtherRR MEDICARE GROUP
KY010056744OtherRR MEDICARE PIN
KY36000818OtherMEDICAID ASC GROUP
KY010056744OtherRR MEDICARE PIN
KY37903705OtherMEDICAID LAB GROUP
KY0016950Medicare ID - Type Unspecified