Provider Demographics
NPI:1083606974
Name:FALLIS, BRYAN V (DPM)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:V
Last Name:FALLIS
Suffix:
Gender:M
Credentials:DPM
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 636389
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-931-0083
Mailing Address - Fax:859-331-2449
Practice Address - Street 1:2300 CHAMBERS CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-331-2440
Practice Address - Fax:859-331-2449
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY244160213E00000X
KY00258213E00000X
OH36003149213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2214213Medicaid
KY80000151Medicaid
KYP00732469OtherRAILROAD MEDICARE
OH2955422Medicaid
OH000000619072OtherANTHEM
KY7100096290Medicaid
OH2214213Medicaid
OH2955422Medicaid
OHFA4262981Medicare PIN
OH000000619072OtherANTHEM
OH6262030001Medicare NSC