Provider Demographics
NPI:1669514840
Name:COUGHTRY, BRENDON M (MD)
Entity type:Individual
Prefix:
First Name:BRENDON
Middle Name:M
Last Name:COUGHTRY
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 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:99 WELLPARK LANE
Practice Address - Street 2:STE 4
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-4919
Practice Address - Country:US
Practice Address - Phone:606-260-8613
Practice Address - Fax:859-977-2683
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42072208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1563218OtherWELLCARE OF KY PROVIDER ID NUMBER
3406022OtherCIGNA PROVIDER ID NUMBER
000001155521OtherANTHEM PIN
WV1669514840Medicaid
KY102719KYIPOtherAETNA BETTER HEALTH OF KY PROVIDER ID NUMBER
VA30015488600001Medicaid
KY7100051000Medicaid
9276417OtherAETNA PROVIDER ID NUMBER
2950152OtherUNITED HEALTHCARE PROVIDER ID NUMBER
IN300012018Medicaid
CS1815900343OtherCARESOURCE PROVIDER ID NUMBER