Provider Demographics
NPI:1023252558
Name:ECKERLE, BRYAN JESSOP
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JESSOP
Last Name:ECKERLE
Suffix:
Gender:M
Credentials:
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3 AUDUBON PLAZA DR
Practice Address - Street 2:LL2
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1300
Practice Address - Country:US
Practice Address - Phone:502-636-4940
Practice Address - Fax:502-636-4941
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY464032084V0102X, 2084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74003114Medicaid