Provider Demographics
NPI:1861478067
Name:BRESSOUD, PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BRESSOUD
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:502-588-0326
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:STE 110
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5700
Practice Address - Country:US
Practice Address - Phone:502-852-6446
Practice Address - Fax:502-852-6649
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27304207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64273048Medicaid
KY3539034000OtherPASSPORT ADVANTAGE
IN200034910Medicaid
KY50020532OtherPASSPORT
KY0366665Medicare PIN
KY50020532OtherPASSPORT
KY0601245Medicare PIN
KY01112012Medicare PIN
KY1271259Medicare PIN