Provider Demographics
NPI:1023092178
Name:BRICKNER, KURT A (DO)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:A
Last Name:BRICKNER
Suffix:
Gender:M
Credentials:DO
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 1700
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0414
Mailing Address - Country:US
Mailing Address - Phone:541-673-5579
Mailing Address - Fax:541-673-0576
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:SUITE 241
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2752
Practice Address - Country:US
Practice Address - Phone:541-673-5579
Practice Address - Fax:541-673-0576
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO20870207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287707Medicaid
OR287707Medicaid
ORR150724Medicare PIN