Provider Demographics
NPI:1881031680
Name:BRECKENRIDGE MEDICAL GROUP, PSC
Entity Type:Organization
Organization Name:BRECKENRIDGE MEDICAL GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-909-3300
Mailing Address - Street 1:974 BRECKENRIDGE LN
Mailing Address - Street 2:SUITE 133
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4619
Mailing Address - Country:US
Mailing Address - Phone:502-909-3300
Mailing Address - Fax:
Practice Address - Street 1:974 BRECKENRIDGE LN
Practice Address - Street 2:SUITE 133
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4619
Practice Address - Country:US
Practice Address - Phone:502-909-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty