1891920773 NPI number — DR. BRANDON BLAKE CONINE M.D.

Table of content: DR. BRANDON BLAKE CONINE M.D. (NPI 1891920773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891920773 NPI number — DR. BRANDON BLAKE CONINE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONINE
Provider First Name:
BRANDON
Provider Middle Name:
BLAKE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891920773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 BURNET AVENUE, 3 SOUTH
Provider Second Line Business Mailing Address:
CENTRAL CREDENTIALING
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45229-3019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-558-5281
Provider Business Mailing Address Fax Number:
513-558-5791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
234 GOODMAN ST
Provider Second Line Business Practice Location Address:
EMERGENCY MEDICINE
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45219-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-558-5281
Provider Business Practice Location Address Fax Number:
513-558-5791
Provider Enumeration Date:
05/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  35 120143 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0077847 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100252520 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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